Patients run a high risk of being harmed during hospital admissions. Adverse events occur in up to 10% of hospitalisations and can cause death, permanent or temporary disability.1
For patients and healthcare workers, these harms and the underlying flaws of their healthcare systems that permit them to happen are deeply upsetting and completely unacceptable.
To improve the safety of patients, national and regional campaigns have been carried through2–5
or are ongoing.6
Improvements have been achieved in some areas such as reductions of catheter-related blood stream infections.7
However, system-wide progress is slow8
and improvements are often limited to particular medical conditions or institutions. Indeed, a recent study9
from the state of North Carolina, an active participant in large-scale patient safety initiatives, concluded that overall rates of harm during 2002–2007 were not reduced. Thus, the challenge to improve the safety of patients in hospitals remains and specific and sensitive measures of harms are needed to assess and monitor the effects of changes to make hospitals safer.
In Denmark, the Operation Life campaign during 2006–2008 focused on patient safety in intensive care and during surgery. An estimated 1654 fewer than expected patients died in the Danish population of 5.5 million during the campaign.10
In 2010, another campaign the Safer Hospital Programme (http://www.sikkerpatient.dk/fagfolk/patientsikkert-sygehus.aspx
) was launched at five pilot hospitals to reduce mortality by 15% and harms by 30% through the implementation of 12 care bundles. The hospitals are required to measure and report harms.
Meanwhile, a gold standard for the measurement of harms does not exist. Methods like voluntary reports only detect a small fraction of harms,11
chart reviews have low inter-rater reliability12
and are very time consuming and so are direct observations of healthcare processes.13
Studies comparing different methods of harm detection have found very little overlap of the detected harms.14
Therefore, complete estimates of the incidence of harms probably require the combination of different methods. Meanwhile, such an approach is time consuming and results are often delayed, which is unsuitable for patient safety campaigns in which frequent and regular measurements of harms are needed to evaluate and monitor the effects of interventions and organisational changes.
The global trigger tool (GTT) has been developed for the purpose of monitoring harms at low cost.15
Harm in this context is defined as an ‘Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalisation, or that results in death’.16
Thus, the tool measures factual harm to patients, while errors not leading to harm, near errors and errors of omission are not included. A GTT review is a trigger-based chart audit of closed patient charts. Two reviewers, usually nurses or pharmacists, each review a limited number of randomly chosen charts with a given set of 56 triggers or “hints” of errors. The finding of such a hint triggers an investigation into whether and, if so, how severely, a patient actually has been harmed. Review time is limited to 20 min per admission. Finally, the two reviewers compare their conclusions and a supervisor, usually a physician, qualifies the number and severity of harms and decides in cases of disagreement. The number of harms is then expressed as a rate, for example, harms per 1000 bed-days. It has been suggested that GTT teams need a limited amount of training and practice to achieve good levels of reliability to identify harms.16–18
The feasibility of the method invites for rapid adoption in healthcare systems around the world where practical ways to measure harms are much in demand. Nevertheless, experiences with the GTT in non-English-speaking countries are limited. Thus, careful calibration of the instrument and the review team that uses it is warranted to avoid evaluating the safety performance of hospitals with imprecise measurements.
A team of Danish experts translated the GTT to Danish19
from the English and a Swedish version.20
The tool was tested in four hospitals in different health regions.21
The harm rate in these hospitals was around 20 per 1000 bed-days. A recent report of harms to Danish patients with cancer found a rate of 68 per 1000 bed-days.22
Notwithstanding these variable rates, policy makers advocate the widespread23
implementation of GTT reviews in Danish hospitals. Meanwhile in our opinion, it is not sufficiently clear as to how the tool performs in the hands of Danish review teams.
The aim of this study was to describe experiences with the GTT in five Danish hospitals and suggest ways to improve the performance of GTT review teams and thus contribute to the accurate measurements of harms.