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  • Reducing Cardiac Arrests in the Acute Admissions Unit: A Quality Improvement Journey
    Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites Regions Regions Overview Africa Asia Pacific Europe Latin America Middle East North America Engage with IHI Engage with IHI Overview Collaboratives Initiatives Membership Programs Fellowship Programs Strategic Partnerships Customized Services Blogs and User Groups Home Resources Publications Reducing Cardiac Arrests in the Acute Admissions Unit A Quality Improvement Journey Publications Resources Resources How to Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites IHI LR Wide Reducing Cardiac Arrests in the Acute Admissions Unit A Quality Improvement Journey Page Content Beckett DJ Inglis M Oswald S Thomson E Harley W Wilson J Lloyd RC Rooney KD Reducing cardiac arrests in the acute admissions unit A quality improvement journey BMJ Quality and Safety 2013 July 4 Epub ahead of print doi 10 1136 bmjqs 2012 001404 Over 17 months a quality improvement project in the acute admissions unit at the Stirling Royal Infirmary in Scotland achieved a 71 percent reduction in the number of cardiac arrests per 1 000 admissions a 68 percent increase in referrals to palliative care per 1 000 admissions per month and a 24 percent relative reduction in the 30 day mortality of patients admitted to unit These results were achieved through the application of improvement methodology to test new innovations and promotion of a safety culture among other changes View article Average Content Rating 1 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by P Keller 2 20 2014 3 50 23 PM Link appears to not work loading Did you find this user comment useful people found this user comment useful Report This

    Original URL path: http://www.ihi.org/resources/Pages/Publications/ReducingCardiacArrestsAcuteAdmissionsQIJourney.aspx (2016-02-01)
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  • Pursuing Perfection: Report from Tallahassee on Reducing Mortality
    the charge We took on the whole issue of mortality in a very intense way she says This meant looking inward combing the records of patients who had died in search of clues and patterns that might be instructive for averting needless deaths and looking outward at other hospitals and to IHI for best practices in reducing mortality Both efforts would pay off bringing Tallahassee s mortality rate down nearly 31 percent over the next three years The Investigation Tallahassee staff used a chart review tool developed by IHI to help hospitals analyze their HSMR in a way that sorts deaths into meaningful categories highlighting problems with the system rather than problems with individual cases By sorting the hospital s most recent 50 deaths into four groupings based on the type of care that was planned and the bed placement i e admitted for comfort care only or not to the ICU or not the Tallahassee staff was able to see that patients admitted for comfort care needed more careful planning such as being placed in hospice care or another more appropriate setting Patients admitted for acute or critical care who subsequently died left behind important clues about system level problems Within this category Tallahassee reviewers began to see three significant patterns Failure to communicate this could mean anything from a physician whose instructions were misunderstood by either patients or staff to a patient who didn t speak up for fear of bothering the nurse Failure to recognize when a patient s condition was worsening and take action Failure to plan including diagnosis treatment and goals While failures in these areas are seldom the cause of death they often contribute The Solution To address each area Tallahassee adopted proven strategies developed by IHI faculty SBAR Staff members use a specific communication framework to discuss all patients similar to the SBAR methodology promoted by IHI This method guides a provider who wishes to consult another to succinctly describe the patient s S ituation The patient s respiratory rate has dropped B ackground She has a history of heart failure A ssessment I think she is deteriorating and R ecommendation I think the respiratory therapist should come see her now This is a useful and effective way to organize information for decision making Rapid Response Teams Unit nurses recognize when patients conditions are declining but often lack the means to mobilize a rescue effort before a medical crisis develops Rapid Response Teams available 24 7 to consult with any provider who is concerned about a patient are typically composed of a critical care trained nurse a respiratory therapist and or an intensivist physician Rapid Response Teams are proving to be effective at preventing medical crises and reducing patients risk of dying At Tallahassee as use of the Rapid Response Team or Medical Emergency Team as they call it increased the number of Code Blue calls for cardiac arrest decreased Multidisciplinary Rounds Tallahassee implemented multidisciplinary rounds to enhance communication and care planning A

    Original URL path: http://www.ihi.org/resources/Pages/ImprovementStories/PursuingPerfectionReportfromTallahasseeonReducingMortality.aspx (2016-02-01)
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  • All
    Measuring Adverse Events The use of triggers or clues to identify adverse events AEs is an effective method for measuring the overall level of harm in a health care organization WIHI The Power to Detect and Improve Revisiting the IHI Global Trigger Tool and Adverse Events April 14 2011 The authors discuss a new study in Health Affairs that finds that the IHI Global Trigger Tool identified at least ten times more confirmed serious events than other methods WIHI The Power to Detect and Reduce Harm IHI s Global Trigger Tool and Adverse Events in the US October 21 2010 This WIHI provides a window into research findings from a series of reports from the Office of Inspector General and their significance for patient safety harm detection improvement work and policy reform going forward The IHI Global Trigger Tool for identifying adverse events is also a focus of the discussion Passport Exclusive Improvement Skills to Empower Front Line Nurses I This recording discusses Developing a Sensitivity to Risk including many tools that can help uncover and reduce risk and patient harm Pursuing Perfection Report from McLeod on Improving Medication Safety McLeod Regional Medical Center a member of IHI s Pursuing Perfection program improves their rate of medication errors by making numerous changes in their care methods beginning with a top down change in culture National Coordinating Council NCC for Medication Error Reporting and Prevention MERP The National Coordinating Council NCC is an independent body of 27 national organizations whose aim is to maximize the safe use of medications and increase awareness of medication errors through open communication increased reporting and promotion of medication error prevention strategies Measuring Rare Events and Time Between Measures This presentation and related articles discuss how measuring the time or number of cases between adverse events such as the number of surgeries between surgical site infections is more effective for detecting changes and verifying improvements Signal and Noise Applying a Laboratory Trigger Tool to Identify Adverse Drug Events among Primary Care Patients This study tests the use of six abnormal laboratory triggers for detecting adverse drug events among adults in outpatient care Deciphering Harm Measurement This article looks at several current approaches to measuring harm Passport Exclusive Improvement Skills to Empower Front Line Nurses II This recording discusses Managing Patient Care Risk Beyond the Checklist How does the front line nurse engage her team foster communication and improve teamwork the three requirements for effective use of a checklist Saving lives by studying deaths Using standardized mortality reviews to improve inpatient safety Substantial variation existed in hospital standardized mortality ratios HSMRs across hospitals in the Kaiser Permanente system In 2008 multidisciplinary teams at KP used the IHI Global Trigger Tool along with other tools to investigate hospital level mortality in order to identify patterns of potential harm and focus improvement efforts Temporal trends in rates of patient harm resulting from medical care A retrospective study of a stratified random sample of 10 hospitals in North Carolina Improvement

    Original URL path: http://www.ihi.org/resources/pages/ViewAll.aspx?FilterField2=IHI_x0020_Topic&FilterValue2=6596896b-d6a6-48cc-81fc-b8fc21990ac4&Filter2ChainingOperator=Or&TargetWebPath=/resources (2016-02-01)
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  • Introduction to Trigger Tools for Identifying Adverse Events
    medications or adverse drug events ADEs use the Trigger Tool for Measuring Adverse Drug Events This tool can be used to collect data on that type of harm only and is helpful when working on improvements to medication systems Another option would be to use only the Medication Module from the IHI Global Trigger Tool which is based on the ADE Trigger Tool In both cases data on medication harm can be collected from the same medical records that are used for the IHI Global Trigger Tool harm measure i e there is no need to obtain a second set of records The only reason to obtain additional records would be if you are focusing on a specific population for targeted improvement e g the pulmonary nursing unit in which case records obtained should be selected from that population only Trigger Tools for Measuring Adverse Events are also available for the Mental Health and Skilled Nursing Facility settings Location or service specific tools such as the Surgical Trigger Tool are designed for use with records from that population only e g surgical inpatients The Intensive Care Unit Adverse Event Trigger Tool is designed to identify harmful events in the ICU and uses records of patients who have been in the ICU for at least two days Harm can also occur outside the hospital Sometimes this is detected on the IHI Global ADE or Surgical Trigger Tools if it results in admission to the hospital Since not all adverse events result in hospital admission there is also an Outpatient Adverse Event Trigger Tool to track harm from medical care across the continuum This tool uses outpatient records and monitors over a longer period of time The IHI Global ADE and Surgical Trigger Tools were designed for use with the adult population However adverse events also occur in pediatric populations and due to unique differences in care and response to care the triggers need to be a bit different The Trigger Tool for Measuring Adverse Events in the Neonatal Intensive Care Unit developed by Child Health Corporation of America and the Vermont Oxford Network in collaboration with IHI builds on the IHI Trigger Tools and offers an option for that specific population With all Trigger Tools data should always be tracked over time and categorized for review such as in a histogram This may identify further focus areas for work Intensive review using a subset of triggers can be very helpful such as anticoagulant related harm in medications and may be used for very focused improvement efforts Related Information IHI Global Trigger Tool Training Resources a suggested plan and materials to help train reviewers on the IHI Global Trigger Tool methodology Training Record Set for IHI Global Trigger Tool to be used when training new reviewers how to use the tool Random Number Generator Tool to generate a random sample of patient records for review Global Trigger Tool Implementation Toolkit Resar RK Rozich JD Classen D Methodology and rationale for the measurement

    Original URL path: http://www.ihi.org/resources/Pages/Tools/IntrotoTriggerToolsforIdentifyingAEs.aspx (2016-02-01)
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  • IHI Trigger Tool for Measuring Adverse Drug Events
    Events provides instructions for conducting a retrospective review of patient records using triggers to identify possible ADEs This tool includes a list of known ADE triggers and instructions for measuring the number and degree of harmful medication events The tool provides instructions and forms for collecting the data you need to measure ADEs per 1 000 Doses and Percent of Admissions with an ADE Read the related article about using the Trigger Tool Rozich JD Haraden CR Resar RK Adverse drug event trigger tool A practical methodology for measuring medication related harm Quality and Safety in Health Care 2003 12 194 200 For more general information on Trigger Tools and how to select the appropriate one see the Introduction to Trigger Tools page Background The Institute for Healthcare Improvement formed the Idealized Design of the Medication System IDMS Group in May 2000 The group of 30 physicians pharmacists nurses and statisticians established an aim to design a medication system that is safer by a factor of 10 and more cost effective than systems currently in use Adverse drug events present the single greatest risk of harm to patients in hospitals Traditional efforts to detect ADEs 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 select and test changes to reduce harm This tool provides an easy to use method for accurately identifying ADEs harm from medications and measuring the rate of ADEs over time Tracking ADEs over time is a useful way to tell if changes the team is making are improving the safety of the medication system Hundreds of hospitals have used this tool to identify ADEs to measure the level of harm from each ADE and to identify areas for improvement in their organizations Related Measures Adverse Drug Events per 1 000 Doses Percent of Admissions with an Adverse Drug Event Directions The Trigger Tool for Measuring Adverse Drug Events contains Background List of ADE Triggers General Instructions Case Studies ADE Patient Record Review Sheet Pediatric ADE Patient Record Review Sheet ADE Monthly Summary Sheet NOTE There is also an interactive Trigger Tool ADEs available on IHI org See also the Trigger Tool for Measuring ADEs in a Mental Health Setting which is based on this version of the Trigger Tool and includes a list of triggers that are known in mental health settings Documents Documents IHI Trigger Tool for Measuring ADEs Featured Content first last Adverse Drug Events per 1 000 Doses The total number of ADEs identified in a sample of patient records divided by the total number of medication doses administered to those patients Multiply the result by 1 000 Introduction to Trigger Tools for Identifying Adverse Events The use of triggers or clues to identify adverse events

    Original URL path: http://www.ihi.org/resources/Pages/Tools/TriggerToolforMeasuringAdverseDrugEvents.aspx (2016-02-01)
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  • Training Record Set for IHI Global Trigger Tool
    Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites IHI LR Wide Training Record Set for IHI Global Trigger Tool Page Content Institute for Healthcare Improvement Cambridge Massachusetts USA The IHI Global Trigger Tool for Measuring Adverse Events is best utilized when used by personnel who have been trained as reviewers for this methodology The IHI Global Trigger Tool Guide within the tool itself includes instructions for training reviewers The first phase of training is conducted using training records that have been provided by IHI These are actual patient records with identifiers removed that have been selected to emphasize key learning points for using the IHI Global Trigger Tool Each record has been reviewed by experienced reviewers and answers on findings are included in the Guide for teaching purposes When new reviewers are ready for phase one of the training download this Training Record Set which can be reviewed on screen or printed The process for review should be followed according the instructions in the IHI Global Trigger Tool Guide It is not unusual for reviewers to find triggers or adverse events that are not listed in the Answers to the Training Records located in the IHI Global Trigger Tool White Paper The answers include the triggers and adverse events most commonly identified by most reviewers when tested Background See the Introduction to Trigger Tools for more information about how to select and use the appropriate Trigger Tool See the IHI Global Trigger Tool Training Resources for a suggested plan and materials for training reviewers Directions Download the tool for detailed information Use this training record set in conjunction with the IHI Global Trigger Tool for Measuring Adverse Events Documents Documents IHI Global Trigger Tool Training Record Set Featured Content first

    Original URL path: http://www.ihi.org/resources/Pages/Tools/TrainingRecordSetforIHIGlobalTriggerTool.aspx (2016-02-01)
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  • Global Trigger Tool Implementation Toolkit
    Orlando Florida USA This compendium of resources was developed or adapted from the Institute for Healthcare Improvement IHI to assist in the hospital s implementation of the IHI Global Trigger Tool The toolkit includes the following Database for data aggregation tracking trending and reporting Example reports Standard operating procedure Educational agenda Project charter Process flow Hospital specific FAQs Directions Florida Hospital Global Trigger Tool Implementation Toolkit is available for download on the SafetyLeaders org website Featured Content first last IHI Global Trigger Tool for Measuring Adverse Events The use of triggers or clues to identify adverse events AEs is an effective method for measuring the overall level of harm in a health care organization Introduction to Trigger Tools for Identifying Adverse Events The use of triggers or clues to identify adverse events is an effective method for measuring the overall level of harm from medical care in a health care organization Average Content Rating 1 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments Show More Comments Loading You are about to report a violation of our Terms of Use All reports are strictly confidential Reason Select One Contains profanity or violence Spam Defamatory Illegal Unlawful Copyright Violation Other Please select a reason for this report Add a Note Your comments were submitted successfully There was an error reporting your complaint More on This Topic Loading Pages first last WIHI New Tools and Thinking for Shared Decision Making January 28 2016 If you work in primary care today odds are good that you re seeing patients with multiple chronic conditions Even if a provider and patient work together to choose the right medications and agree on making some lifestyle changes that will improve health the best laid plans

    Original URL path: http://www.ihi.org/resources/Pages/Tools/GlobalTriggerToolImplementationToolkit.aspx (2016-02-01)
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  • IHI Global Trigger Tool for Measuring Adverse Events
    and used the IHI Global Trigger Tool as one method of detection This extensive use of the IHI Global Trigger Tool has provided the opportunity to collect feedback from those using the tool and identify opportunities to clarify definitions and update material Translations and Adaptations of the Tool Translated versions of the IHI Global Trigger Tool are available in Danish German and Swedish The UK version of the tool has been adapted to reflect the local UK context This version was last revised in September 2008 as part of IHI s continuing work in the UK with the Safer Patients Initiative NHS Institute for Innovation and Improvement and other related initatives The revisions are as follows The following triggers have been added back into the tool G7 Complication of procedure or treatment G8 Transfer to higher level of care M5 Abrupt medication stop The supporting explanation for G7 and G8 from the 2005 UK version of the IHI Global Trigger Tool has been retained A paragraph has been provided for M5 as the 2005 text was not precisely what is being taught in the UK Related Literature and Information Classen DC Lloyd RC Provost L Griffin FA Resar R Development and evaluation of the Institute for Healthcare Improvement Global Trigger Tool Journal of Patient Safety 2008 Sep 4 3 169 177 Adler L Denham CR McKeever M Purunton R Guilloteau F Moorhead D Resar R Global Trigger Tool Implementation basics Journal of Patient Safety 2008 Dec 4 4 245 249 See related resources Training Record Set for the IHI Global Trigger Tool IHI Global Trigger Tool Training Resources Directions The IHI Global Trigger Tool for Measuring AEs contains Background on Development and Methodology Rules and Methods for Use Triggers and Definitions Training Instructions Stories from Experienced Organizations References and Resources Documents Documents IHI Global Trigger Tool UK Version IHI Global Trigger Tool Danish Translation IHI Global Trigger Tool German Translation IHI Global Trigger Tool Swedish Translation IHI Global Trigger Tool Italian Translation IHI Global Trigger Tool Average Content Rating 4 users Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments by irene ivicente 10 20 2015 5 23 10 PM excelent do you have it in spanish loading Did you find this user comment useful people found this user comment useful Report This by Edmundo Antezana 9 30 2015 10 56 52 PM exelente tendran version español loading Did you find this user comment useful people found this user comment useful Report This by Liu Jm 1 14 2015 7 15 00 AM I want to know when IHI define the Tool as Global Trigger Tool the first section fo GTT white paper I can t find it who can help me loading Did you find this user comment useful people found this user comment useful Report This by Noora Saeed 1 9 2014 1 52 18 AM great value loading Did you find this user comment useful people

    Original URL path: http://www.ihi.org/resources/Pages/Tools/IHIGlobalTriggerToolforMeasuringAEs.aspx (2016-02-01)
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