title: Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting.
abstract: BACKGROUND
  Adverse drug event (ADE) detection is an important priority for patient safety research. Trigger tools have been developed to help identify ADEs. In previous work we developed seven concurrent, action-oriented, electronic trigger algorithms designed to prompt clinicians to address ADEs in outpatient care.
  
  
  OBJECTIVE
  We assessed the potential adoption and usefulness of the seven triggers by testing the positive predictive validity and obtaining stakeholder input.
  
  
  METHODS
  We adapted ADE triggers, "bone marrow toxin-white blood cell count (BMT-WBC)," "bone marrow toxin - platelet (BMT-platelet)," "potassium raisers," "potassium reducers," "creatinine," "warfarin," and "sedative hypnotics," with logic to suppress flagging events with evidence of clinical intervention and applied the triggers to 50,145 patients from three large health care systems. Four pharmacists assessed trigger positive predictive value (PPV) with respect to ADE detection (conservatively excluding ADEs occurring during clinically appropriate care) and clinical usefulness (i.e., whether the trigger alert could change care to prevent harm). We measured agreement between raters using the free kappa and assessed positive PPV for the trigger's detection of harm, clinical usefulness, and both. Stakeholders from the participating health care systems rated the likelihood of trigger adoption and the perceived ease of implementation.
  
  
  RESULTS
  Agreement between pharmacist raters was moderately high for each ADE trigger (kappa free > 0.60). Trigger PPVs for harm ranged from 0 (Creatinine, BMT-WBC) to 17 percent (potassium raisers), while PPV for care change ranged from 0 (WBC) to 60 percent (Creatinine). Fifteen stakeholders rated the triggers. Our assessment identified five of the seven triggers as good candidates for implementation: Creatinine, BMT-Platelet, Potassium Raisers, Potassium Reducers, and Warfarin.
  
  
  CONCLUSIONS
  At least five outpatient ADE triggers performed well and merit further evaluation in outpatient clinical care. When used in real time, these triggers may promote care changes to ameliorate patient harm.
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR) ; VA Boston Healthcare System ; Boston University School of Medicine.
authors.forename: Hillary J
authors.initials: HJ
authors.lastname: Mull
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR) ; VA Boston Healthcare System ; Boston University School of Medicine.
authors.forename: Amy K
authors.initials: AK
authors.lastname: Rosen
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR) ; Edith Nourse Rogers Memorial Veterans Hospital ; Department of Quantitative Health Sciences, University of Massachusetts Medical School ; Boston University School of Public Health.
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Shimada
authors.affiliation: Center for Healthcare Organization and Implementation Research (CHOIR) ; VA Boston Healthcare System ; Sawyer Business School, Suffolk University.
authors.forename: Peter E
authors.initials: PE
authors.lastname: Rivard
authors.affiliation: Health Catalyst.
authors.forename: Brian
authors.initials: B
authors.lastname: Nordberg
authors.affiliation: Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System ; University of Utah.
authors.forename: Brenna
authors.initials: B
authors.lastname: Long
authors.affiliation: Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System ; University of Utah.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Hoffman
authors.affiliation: Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System ; University of Utah.
authors.forename: Molly
authors.initials: M
authors.lastname: Leecaster
authors.affiliation: University of Utah ; Intermountain Healthcare.
authors.forename: Lucy A
authors.initials: LA
authors.lastname: Savitz
authors.affiliation: Boston University School of Medicine ; Boston Medical Center.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Shanahan
authors.affiliation: Office of the National Coordinator for Health IT.
authors.forename: Amy
authors.initials: A
authors.lastname: Helwig
authors.affiliation: Geriatrics Research Education and Clinical Center, VA Salt Lake City Health Care System ; University of Utah.
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Nebeker
keywords: adverse drug events; outpatient care; patient safety; trigger tools