title: Validation of triggers and development of a pediatric trigger tool to identify adverse events.
abstract: BACKGROUND
  Little is known about adverse events (AEs) in pediatric patients. Record review is a common methodology for identifying AEs, but in pediatrics the record review tools generally have limited focus. The aim of the present study was to develop a broadly applicable record review tool to identify AEs in pediatric inpatients.
  
  
  METHODS
  Using a broad literature review and expert opinion with a modified Delphi process, a pediatric trigger tool with 88 triggers, definitions, and descriptions including AE preventability decision support was developed and tested in a random sample of 600 hospitalized pediatric patients admitted in 2010 to a single university children's hospital. Four registered nurse-physician teams performed complete two-stage retrospective reviews of 150 records each from either neonatal, surgical/orthopedic, medicine, or emergency medicine units.
  
  
  RESULTS
  Registered nurse review identified 296 of 600 records with triggers indicating potential AEs. Records (n = 121) with only false positive triggers not indicating any potential AEs were not forwarded to the next review stage. On subsequent physician review, 204 (34.0%) of patients were found to have had 563 AEs, range 1-27 AEs/patient. A total of 442 preventable AEs were found in 161 patients (26.8%), range 1-22. Overall, triggers were found 3,598 times in 417 (69.5%) records, with a mean of 6 (median 1, range 0-176) triggers per patient. The overall positive predictive value of the triggers was 22.9%, (range 0.0-100.0%). The final pediatric trigger tool, developed with a second Delphi round, required 29 triggers.
  
  
  CONCLUSIONS
  AEs are common in pediatric patients and most are preventable. The main contributions of this study are to further develop and adapt trigger definitions, including AE preventability decision support, to introduce new triggers in pediatric care, as well as to apply pediatric triggers in different clinical specialties. Our findings resulted in a national pediatric trigger tool, and might also be adapted internationally. The pediatric trigger tool can help healthcare organizations to measure and analyze the AEs occurring in hospitalized children in order to improve patient safety.
authors.affiliation: Department of Orthopedics, Danderyd Hospital, 182 88, Stockholm, Sweden. maria.unbeck@ds.se.|Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88, Stockholm, Sweden. maria.unbeck@ds.se.
authors.forename: Maria
authors.initials: M
authors.lastname: Unbeck
authors.affiliation: Division of Pediatrics, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden. synnove.lindemalm@karolinska.se.|Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 171 77, Stockholm, Sweden. synnove.lindemalm@karolinska.se.
authors.forename: Synnöve
authors.initials: S
authors.lastname: Lindemalm
authors.affiliation: Division of Pediatrics, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden. per.nydert@karolinska.se.|Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 171 77, Stockholm, Sweden. per.nydert@karolinska.se.
authors.forename: Per
authors.initials: P
authors.lastname: Nydert
authors.affiliation: Division of Pediatrics, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden. britt-marie.ygge@karolinska.se.|Department of Women's and Children's Health, Karolinska Institutet, 171 77, Stockholm, Sweden. britt-marie.ygge@karolinska.se.
authors.forename: Britt-Marie
authors.initials: BM
authors.lastname: Ygge
authors.affiliation: Unit for Quality and Patient Safety, Karolinska University Hospital, 171 76, Stockholm, Sweden. urban.nylen@karolinska.se.|SALAR (Swedish Association of Local Authorities and Regions), 118 82, Stockholm, Sweden. urban.nylen@karolinska.se.
authors.forename: Urban
authors.initials: U
authors.lastname: Nylén
authors.affiliation: Unit for Quality and Patient Safety, Karolinska University Hospital, 171 76, Stockholm, Sweden. carina.berglund@karolinska.se.|SALAR (Swedish Association of Local Authorities and Regions), 118 82, Stockholm, Sweden. carina.berglund@karolinska.se.
authors.forename: Carina
authors.initials: C
authors.lastname: Berglund
authors.affiliation: Division of Pediatrics, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, 171 76, Stockholm, Sweden. karin.pukk-harenstam@karolinska.se.|Medical Management Centre, Karolinska Institutet, 171 77, Stockholm, Sweden. karin.pukk-harenstam@karolinska.se.
authors.forename: Karin Pukk
authors.initials: KP
authors.lastname: Härenstam
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems / Q000295:instrumentation*; D002648:Child; D002673:Child, Hospitalized; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D008297:Male; D019300:Medical Errors / Q000009:adverse effects*; D061214:Patient Safety; D010372:Pediatrics; D015985:Precipitating Factors; D015203:Reproducibility of Results; D012189:Retrospective Studies