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Qual Saf Health Care 12:194-200 doi:10.1136/qhc.12.3.194
  • Medication safety

Adverse drug event trigger tool: a practical methodology for measuring medication related harm

  1. J D Rozich1,
  2. C R Haraden2,
  3. R K Resar1,2
  1. 1Luther Midelfort, Mayo Health System, Eau Claire, WI 54703, USA
  2. 2Institute for Healthcare Improvement, Boston, USA
  1. Correspondence to:
 Dr J D Rozich, Luther Midelfort, Mayo Health System, Eau Claire, WI 54703, USA; 
 rozich.john{at}mayo.edu
  • Accepted 8 February 2003

Abstract

Adverse drug events continue to be the single most frequent source of healthcare mishaps, continually placing patients at risk of injury. This is not unexpected, given that drug treatment is the most common medical intervention and medication use is a highly complex, multidisciplinary, and largely manual process. Assessing the actual safety of drug use has been historically difficult, mainly because traditional methods such as chart audits and voluntary reporting of data have been shown to be expensive, insensitive, and largely ineffective for detecting mistakes in drug administration and drug related adverse clinical events (ADEs). Computerized methods for detecting ADEs, employing sentinel words or “triggers” in a patient’s medical record, are effective but expensive and require customized software linkage to pharmacy databases. This paper describes the use of the “trigger tool”, a relatively low cost and “low tech” modification of the automated technique. The adapted technique appears to increase the rate of ADE detection approximately 50-fold over traditional reporting methodologies.

Footnotes

  • * Medical background is a generic term used in this paper to underscore that nurses, laboratory, medical informatics, and pharmacy technicians, administrators and physicians were participants in learning the trigger tool technique. The distinction is to underscore the concept that individuals unfamiliar with the medical record or any aspect of medical practice are unlikely to become competent in the role of reviewing or auditing medical records with the trigger tool.

  • See editorial commentary, pp 165–6