Developing and implementing a standardized process for global trigger tool application across a large health system

Jt Comm J Qual Patient Saf. 2013 Jul;39(7):292-7. doi: 10.1016/s1553-7250(13)39041-2.


Background: To complement voluntary adverse event reporting, which may detect only specific categories of harms and may represent merely a fraction of actual adverse events, the Adventist Health System (AHS) began using the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) to more accurately gauge the number, types, and severity levels of adverse events and developed a centralized process to do so uniformly.

Methods: AHS began using the GTT in 2009 in 25 of its 42 hospitals that used a common electronic medical record (EMR). The common EMR and centralized record review enables AHS to apply the GTT uniformly and provides consistency of data collected. AHS sends quarterly reports to participating facilities to communicate findings and provides case studies illustrating the most egregious harms. Case study recipients are encouraged to further examine patient records, explore events leading to harm, and share the information with process/quality improvement committees, medical executive committees, and boards of directors to identify opportunities for quality improvement. AHS staffing and record review processes have evolved since 2009.

Results: A GTT review of 17,295 patient records indicated that adverse events clustered as medication-related glycemic events; medication-related delirium, confusion, or oversedation related to analgesics, sedatives, and muscle relaxants; pressure ulcers; medication-related bleeding; and medication-related skin/mucosal reaction/itching.

Conclusions: The AHS process demonstrates how a large health system uses the GTT to detect harms. Since 2009 AHS has improved and streamlined its reporting, data entry and review processes. AHS used major harms findings to initiate systemwide collaborative improvement projects for glycemic management and pressure ulcers.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Blood Glucose
  • Confusion / chemically induced
  • Drug Eruptions
  • Drug-Related Side Effects and Adverse Reactions / classification
  • Drug-Related Side Effects and Adverse Reactions / prevention & control*
  • Electronic Health Records*
  • Hemorrhage / chemically induced
  • Humans
  • Inservice Training
  • Medication Errors / classification
  • Medication Errors / prevention & control*
  • Pressure Ulcer
  • Safety Management / organization & administration*


  • Blood Glucose