Automated harm trigger system IDs patients at risk

Editor's Note

In this study, an automated harm trigger system developed by the Adventist Health System Patient Safety Organization (Altamonte Springs, Florida) enabled the identification of patients who may have been harmed or at risk for harm.

Nurse reviewers analyzed electronic health records of current patients with positive triggers to determine if harm had occurred, and then classified the harm as hospital-acquired or outside-acquired.

During an 11-month period, the automated system found 2,696 harms (hospital-acquired and outside-acquired) compared to 132 harms found using a manual review process. Almost one-third were acquired outside the hospital, and hypoglycemia was the most frequently identified harm.

The system revealed more harm than regulatory harm reduction programs and a broader scope of harm, which led to deeper understanding of patient safety vulnerabilities, the researchers say.

From 2009 through 2012, the Adventist Health System Patient Safety Organization (AHS PSO) used the Global Trigger Tool method for harm identification and demonstrated harm reduction. Although the awareness of harm demonstrated opportunities for improvement across the system, leaders determined that the human and fiscal resources required to continue with a retrospective manual harm identification process were unsustainable. In addition, there was growing concern that the identification of harm after the patient's discharge did not allow for intervention during the hospital stay.