title: Identifying Previously Undetected Harm: Piloting the Institute for Healthcare Improvement's Global Trigger Tool in the Veterans Health Administration.
abstract: BACKGROUND
  Adverse event (AE) surveillance may be enhanced by the Institute for Healthcare Improvement's Global Trigger Tool (GTT). A pilot study of the GTT was conducted in one Veterans Health Administration (VA) facility to assess the rates, types, and harm of AEs detected and to examine the overlap in AE detection between the GTT and existing surveillance mechanisms.
  
  
  METHODS
  GTT guidelines were followed and medical records were reviewed for 17 weeks of acute care hospitalizations. Investigators met monthly, first to adjudicate discordant reviewer categorizations of harm and later to categorize the AEs detected using standardized definitions. GTT-detected AEs were compared with incident reports, Patient Safety Indicators, and the VA Surgical Quality Improvement Program.
  
  
  RESULTS
  Medical records were reviewed for 273 of 1980 eligible cases. Using the GTT, a total of 109 AEs were identified. More than 1 of 5 hospitalizations (21%) were associated with an AE. The majority of AEs detected (60%) were minor harms; there were no deaths attributable to medical care. Ninety-six of the 109 AEs (88%) were not detected by other measures.
  
  
  CONCLUSIONS
  The GTT identified previously undetected AEs at one VA. The GTT has the potential to track AEs and guide quality improvement efforts in conjunction with existing AE surveillance mechanisms.
authors.affiliation: Measurement to Assess Patient Safety, Patient Safety Center of Inquiry (Drs Mull, Brennan, Rosen, and Simon and Mr Chan), Center for Healthcare Organization and Implementation Research (Drs Mull, Rosen, and Simon and Mr Chan), Department of Nursing (Ms Folkes), and Section of General Internal Medicine (Drs Hermos and Simon), VA Boston Healthcare System, Boston, Massachusetts; Department of Surgery, Boston University School of Medicine, Boston, Massachusetts (Drs Mull and Rosen); Clinical Center Nursing Department, Research and Practice Development Section, National Institutes of Health, Bethesda, Maryland (Dr Brennan); and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts (Dr Simon).
authors.forename: Hillary J
authors.initials: HJ
authors.lastname: Mull
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Brennan
authors.forename: Tiffany
authors.initials: T
authors.lastname: Folkes
authors.forename: John
authors.initials: J
authors.lastname: Hermos
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Chan
authors.forename: Amy K
authors.initials: AK
authors.lastname: Rosen
authors.forename: Steven R
authors.initials: SR
authors.lastname: Simon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D019300:Medical Errors; D061214:Patient Safety; D010865:Pilot Projects; D058996:Quality Improvement; D017751:Safety Management; D014481:United States; D014493:United States Department of Veterans Affairs; D058014:Veterans Health