Identifying and Preventing Adverse Events

The use of trigger tools for healthcare facilities to identify adverse events (AEs), their possible sources and their level of harm to patients has been an accepted and challenging practice for patient safety for over a decade. But now there’s an easy-to-use tool focused on the specific needs of skilled nursing facilities (SNFs).

An AE is defined in the tool as unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death. AEs are frequent and costly to patients, insurers and providers.

Last December at the Institute for Healthcare Improvement’s 27th Annual National Forum on Quality Improvement in Healthcare in Orlando, presenters reviewed a methodology developed to identify AEs in SNFs. The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events is based on the IHI Global Trigger Tool (GTT) methodology, which involves a retrospective review of a random sample of inpatient hospital records, using clues or “triggers” to identify possible AEs. 

“In our earlier work on the GTT, as we were trying to improve safety, we discovered it was very difficult to find an appropriate measure to understand whether we were improving,” says Frank Federico, RPh, vice president and senior expert on patient safety at the IHI. “Many relied on voluntary reports in what we would describe as incident reporting systems. Those systems are a source of information, but they are not reliable in the sense that you have to know there was harm or a mistake. You have to be willing to report, there has to be a culture of safety to report, and it has to be easy to do.”

The harm rates in SNFs are similar to those in acute care hospitals, but the setting presents unique challenges. Public health researchers have established that with traditional reporting efforts, only 10%–20% of errors are ever reported, and of those, 90%–95% cause no harm to patients, according to the SNF tool.

In 2014 the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) estimated that 33% of Medicare beneficiaries admitted to SNFs following a hospital stay experienced an AE during their SNF stay. Fifty-nine percent of the identified harm events were preventable, largely because of substandard treatment, inadequate resident monitoring and failure to provide necessary care. The OIG’s report also found that hospital care resulting from AEs in SNFs cost Medicare an estimated $208 million in one month and $2.8 billion in one year.

“We looked at developing a methodology that took advantage of information that already existed in the medical record,” Federico says. “The gold standard for any research has been total chart review. That is, you look at the chart for the entire stay, you read every page, every note and every lab value. That’s quite expensive and time-consuming. It can be done if you’re doing research, but if you want a constant measure of how well you’re performing, it’s so prohibitively expensive and time-consuming that no one would do it.”

Based on that OIG report results and findings, the Centers for Medicare & Medicaid Services (CMS) developed the Adverse Event Trigger Tool.

“The tool was made available by the OIG, and IHI helped with the training for its use. When we determined the tool was valuable, we decided to develop a guide to use it, because we knew if we just put it out there, it would not be used in the manner designed. That’s why we developed the SNF trigger tool that’s on our website. It provides both the instructions on the tool and the tool itself,” Federico says.

Developing the SNF Tool

Based on the GTT methodology, the IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events provides a method for accurately identifying and measuring the rate of adverse event incidence over time in SNFs. Input for developing the SNF tool came from geriatricians, geriatric nurses, nurse practitioners and pharmacists.

“We adopted a methodology that took some of the best of the chart review, used a sampling methodology, and as a result facilities are able to determine their rate of harm,” according to Federico.

The SNF tool also provides:

• Detailed guidance on designing a trigger tool review;

• A list of SNF-specific triggers and definitions;

• Examples of adverse events that occur in SNFs; and

• An extensive Frequently Asked Questions section.

The SNF tool emphasizes scanning for specific patterns that might reveal triggers that would indicate harm. Federico says they recommend two people be in the review process, because they found using two has a 20% higher rate of identifying an event.

“Remember, you’re sampling and skimming through the record, so one person is less likely to find all the events we’re looking for,” he says. “But with two there is a greater likelihood of discovering triggers.”

However, Federico acknowledges it’s a labor-intensive process, so it’s acceptable to use just one nurse as long as you’re consistent using the same methodology. He notes too that IHI is working on an automated way of looking at inpatient charts using the GTT methodology with a goal of taking that concept and applying it to the electronic health record for SNFs, but that is still in development.

The reason the second phase of review adds a physician is because of his/her training. They can determine whether what is considered harm is related to the care or disease process, and also they can determine the level of severity of that harm. The SNF tool has extensive charting to determine the severity of harm.

How Much, Not How Many

Federico points out that what they did differently from other tools available was to focus on any harm the patient experienced, whether preventable or nonpreventable. The process doesn’t care how many triggers you collect; it’s how much harm you understand the patient experienced.

“So a trigger might be the administration of an antihistamine, which could be either because the patient had an allergic reaction or to help a child sleep,” he says. “If the trigger fires, you would look in the notes and ask, ‘Why did this patient get an antihistamine?’ If it’s because they had an allergic reaction, then it’s harm, and you would count that.” 

It’s important to count everything. “The reason we do that is, if we spend more time deciding if something is preventable or nonpreventable, we spend too much time debating and not enough time improving,” Federico adds.

He also notes that by including what is considered nonpreventable today, they are making inroads for healthcare to discover how to make improvements in the future.

“I like to use the example of my days working in pharmacy in the pediatric setting, where we had very dangerous drugs that were causing some serious side effects,” he says. “We could have said, ‘Well, that’s what happens with chemotherapy.’ Instead we kept challenging and asking how we could do it without harming patients. As a result there are many new drugs that have come out that counteract the effects of chemotherapy and allow us to push the envelope in treatment plans. What may have killed the patient five years ago becomes the standard treatment plan today because we have all these adjunctive therapies that go along with it that rescue the patient from the toxic effects of chemotherapy.”

Conclusion

The SNF tool as presented is still very new, so there are scant results at this point, but the IHI is working with long-term care facilities and SNFs to implement it. As of January 13, there were 1,656 views of the tool and 587 downloads.

“Generally, we have an offering where we train people through WebEx or other technology to use the tools, and it is during that time that we hear about qualitative information on the tool,” he says. “When you’re running a healthcare organization, one key critical to success is asking, ‘Are we providing good care to our patients?’ So unless you have some other indicator that’s able to give you this kind of information, then you should be using this tool. You probably have financial audits in place—shouldn’t auditing patient care be just as important as auditing finances? Also, with the OIG producing this tool for CMS, you can almost see the implication that CMS is asking itself why it should pay for care where you have caused the harm.”

The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events is available for download at: https://www.ihi.org/resources/Pages/Tools/SkilledNursingFacilityTriggerTool.aspx.