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Detection of adverse events in surgical patients using the Trigger Tool approach
  1. F A Griffin1,
  2. D C Classen2
  1. 1
    Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
  2. 2
    First Consulting Group, Long Beach, California, USA
  1. F A Griffin, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138, USA; fgriffin{at}


Background: Most studies of healthcare complications identify surgery as a major contributor to the overall burden of complicated care that leads to injury or death. Indeed, surgical adverse events account for one-half to three-quarters of all adverse events in these studies. Despite the intensive current focus on improving medical quality and safety, only a minority of quality improvement efforts are focused on surgery. This study reports on the development and testing of a Trigger Tool to detect adverse events among patients undergoing inpatient surgery.

Methods: Rather than relying on traditional voluntary reporting for safety outcome measures such as incident reports, surgical peer review, or morbidity and mortality conferences, the Institute for Healthcare Improvement (IHI) has employed a new method for the detection of surgical adverse events (SAEs). This approach, commonly referred to as the “Trigger Tool”, identifies adverse events using a form of retrospective record review that has been developed and implemented in many areas of care.

Results: During a 12-month IHI Perioperative Safety Collaborative, 11 hospitals voluntarily submitted data from surgical inpatient record reviews. In 854 patients, 138 SAEs were detected in 125 records for a rate of 16 SAEs per 100 patients or 14.6% of patients; 61 (44%) of these events contributed to increased length of stay or readmission and 12 (8.7%) events required life-saving intervention or resulted in permanent harm or death. Hospital review teams reported verbally that most of the events identified during the Trigger Tool review process had not been detected or reported via any other existing mechanism.

Conclusions: The IHI Surgical Trigger Tool may offer a practical, easy-to-use approach to detecting safety problems in patients undergoing surgery; it can be the basis not only for estimating the frequency of adverse events in an organisation, but also determining the impact of interventions that focus on reducing adverse events in surgical patients.

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  • Funding: The Institute for Healthcare Improvement (IHI) sponsored all work related to the development and testing of the Surgical Trigger Tool, including the Perioperative Safety Collaborative. FG is a full-time employee of the IHI.

  • Competing interests: DC is an employee of First Consulting Group (a technology services company) and holds stock in the company. He is an adviser and hold stocks in Theradoc (a medical software company), and was contracted as a faculty member for the IHI Perioperative Safety Collaborative.