Improving Adverse Drug Events Detection in Al Khor Hospital using IHI Trigger Tool

Purpose:
Al Khor Hospital (AKH) staff have historically reported all Adverse Drug Events / Reactions using the Occurrence, Variance, Accident form since 2004. staff reporting only Adverse Drug Reactions (when patients develop signs and symptoms(itching, and fever); some ADEs went unreported (no S&S).

Background/Significance:
Traditional efforts to detect adverse events have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients in order to quantify the degree and severity of harm, and to select and test changes to reduce harm.

Methods:
A Multidisciplinary Trigger Tool Team was formed in June 2011 comprising members from Hospital Quality Management Department (Quality Management Reviewer), Medical Administration, two hospital clinical pharmacists, and two senior nurses to conduct a retrospective (closed file) review of twenty medical records randomly. the project team members educated on IHI trigger Tool methodology and its implementation. The tool includes a list of 19 triggers for potential ADEs. Patient harm is categorized by ascending levels of harm severity (Temporary harm
level E to death level I). Upon finding from the closed file review we decided to start open file review to obtain more accurate data.

Results:
An average of 20 patients per 100 admissions had ADE. When compared against actual ADEs reported through Hospital OVA reporting system only 1 ADE per month was reported. From the 122 closed file review 24 files contained a total 50 ADEs. It was also noticed that some patients experienced more than one adverse event.The overall rate was 20 ADEs per 100 admissions (range: 5–33). 3 ADEs with harm category(F: temporary harm to the pateint and required initial or prolonged hospitalization)and 47 ADEs with harm category (E: temporary harm to the patient and required intervention). Prospective reviwe process for Medical Records is more effecient in identifiting Trigerrs for potential ADE.

Conclusions and Implications for Practice:
95% of ADEs which potentially might have harm patients went unreported through the OVA reporting system. IHI Trigger Tool prove its reliability and effectiveness in detection of ADE and its level of harm to the patients.