The Global Trigger Tool Content Session

1
The Global Trigger Tool Content Session

• Liz Baines GTT Specialist
• Lisa Williams Data Analyst

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Welcome
3
Programme

• 12.00 -12.20 Over view of GTT in Wales
• 12.20 -1.00 Communication and the GTT (Panel
  discussion)
• 1- 1.50 pm LUNCH
• 2.00 - 3.40 Feedback
• 3.40 4.00 Planning and next steps

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2 Years and Counting

• The 1000 Lives Campaign is aiming to
• save 1000 lives and to
• avoid 50,000 episodes of harm
• in Welsh healthcare between
• 21st April 2008 and 21st April 2010

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Measures of Harm

• Conventional approaches to quantifying adverse
  events
• Voluntary Incident Reporting
• Record Reviews
• Observational databases
• The Global Trigger Tool was devised by the IHI
• This was based on the principle of Triggers

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Why Trigger Tools?

• Trigger Tools focus on identifying harm as
  opposed to errors
• By focusing on events experienced by patients it
  can help shift the culture from individual blame
  for errors.
• This can facilitate system redesign

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GTT Approach

• Provides a tool for a systematic case note review
  
• 20 cases per month
• Review for triggers then asses for harm
• Triggers are in modules
• Calculates rate of harm adverse event rate per
  1000 patient days

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Outcome Measure
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What does this mean?

• Adverse event rate per 1000 patient days
• 40 per 1000 pt days 4 per 100
• In a 25 bed ward 4 incidents in every 4 days
• That is 1 patient harmed in every 24 hours on
  every ward
• 20 per 1000 bed days 2 per 100 pt days
• In a 25 bed ward 2 incidents in 4 days
• That is a patient is harmed every other day

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A Plea Timely Reporting
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What is the data telling us?

• Lisa Williams
• Data Analyst

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All Wales Triggers by module
13
Frequently occurring triggers
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All Wales Events
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What the data is telling us?
Where is most of the harm occurring?
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What the data is telling us?
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Demonstration of GTT Analysis Tool
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Any Questions?
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Questions

• What is the GTT telling us about the
  organisation?
• How Where is this information being
  communicated?
• What is the process for dealing with the serious
  cases we identify?
• What are we doing to improve our systems and
  processes?