Posted 30th Jan 2013 in Other Topics

The Health Quality & Safety Commission welcomes the findings of a study on adverse drug events published in the New Zealand Medical Journal recently.

This paper describes the results of a collaborative between Counties Manukau, Capital & Coast and Canterbury district health boards (DHBs), who implemented the Adverse Drug Event Trigger Tool (ADETT) to measure the extent of patient harm caused by adverse drug events.

The trigger tool methodology was developed by the Institute for Healthcare Improvement (IHI). It involves a systematic process of reviewing a random set of medical records monthly using specific sets of triggers, which are clues that harm may have occurred. Positive triggers signal the need for a more thorough search of the relevant parts of the medical record to determine if harm has occurred. Identified harms are classified and counted.

The first trigger tool was the Adverse Drug Event Trigger Tool (ADETT) which focused solely on identifying harm caused by medications. Subsequently, the Global Trigger Tool (GTT) was developed, including additional sets of triggers to enable identification of harms across a broader spectrum of care. These tools have been well validated and are internationally recognised.

The focus on harm versus error means the approach focuses on systems issues contributing to harm rather than on individuals. The information gained from analysis of the data collected is used to inform patient safety initiatives.

These three DHBs have led the way for other DHBs in New Zealand to not only implement the ADETT, but to consider taking up the GTT which is a more global measure, incorporating the medication triggers. Twelve DHBs have implemented, or are in the process of implementing, the ADETT and GTT.

Commission chief executive Dr Janice Wilson says that the findings help us to understand the type and extent of patient harm occurring in the health and disability sector, and is consistent with international research.

“We know that voluntary reporting of adverse events only identifies around 10 percent of patient harm, and we are working actively with the sector to improve reporting by these mechanisms.”

The study is further confirmation of the benefits of using trigger tools, which give a more complete picture of patient harm.

A copy of the New Zealand Medical Journal article and a link to the Commission’s GTT guide is available below.

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