NUR 659 Module 7 Milestone Three Example

Milestone Three: Measuring Harm With a Trigger Tool and Safety Culture With a Validated Survey

[Student Name]

Southern New Hampshire University

NUR 659: Healthcare Safety, Just Culture, and Regulation

Module Seven Milestone Three

[Instructor Name]

[Date]

Milestone Three: Measuring Harm With a Trigger Tool and Safety Culture With a Validated Survey

A hospital cannot improve what it cannot see. Westbrook, a composite 220-bed community hospital, has measured safety mainly by counting incident reports, about forty a month, and by tracking a few administrative indicators drawn from billing data. The course's earlier modules showed why this is not enough: national record review studies find adverse events in a large share of admissions, and reporting depends on staff noticing harm and feeling safe to report it. This milestone plans a measurement system that captures harm more completely and measures the safety culture that shapes reporting and practice. It argues that active detection with a trigger tool, a validated culture survey and clear rules for interpreting results will give Westbrook a truer picture and a better basis for action.

Why Incident Reports and Administrative Data Fall Short

Classen et al. (2011) compared three methods of detecting adverse events in the same records at three hospitals with established safety programs: the hospitals' voluntary reporting systems, the Agency for Healthcare Research and Quality's patient safety indicators drawn from administrative data and the Global Trigger Tool. The trigger tool identified adverse events in about a third of admissions and found roughly ten times as many events as either of the other methods. Voluntary reporting captured only a small fraction of harm, and the administrative indicators missed most events because many types of harm do not appear in billing codes. The authors concluded that hospitals relying on these methods would substantially underestimate harm and misdirect their improvement efforts.

The Global Trigger Tool Method

Griffin and Resar (2009) describe the Global Trigger Tool as a structured method in which trained reviewers screen a random sample of closed inpatient records for triggers, clues that an adverse event may have occurred, such as administration of naloxone or dextrose, a transfusion, a return to surgery, a sudden transfer to a higher level of care or a new pressure injury. When a trigger is found, the reviewer examines the relevant part of the record to determine whether an adverse event occurred and its severity. A physician confirms each event. The method recommends reviewing about twenty records a month, with a time limit per record so that review is consistent and sustainable, and expressing results three ways: events for every thousand patient days, events for every hundred admissions and the share of admissions with any event.

Applying the Method at Westbrook

Two experienced nurses from the quality department will be trained as primary reviewers, with a hospitalist as the confirming physician. Each month, twenty adult inpatient records will be randomly selected from discharges, excluding patients under 18 and stays shorter than 24 hours, as the method suggests. Reviewers will spend no more than twenty minutes per record. Events will be classified by severity using the categories the method adopts, from temporary harm requiring intervention to death, and by type, such as medication, procedural, infection or care-related events. The pilot month found six adverse events in twenty records, including two medication-related hypoglycemic episodes and a hospital-acquired pressure injury, none of which had been reported through the incident system.

Measuring Safety Culture

Harm rates show outcomes; safety culture helps explain them. Sexton et al. (2006) described the Safety Attitudes Questionnaire, a survey of health care workers' attitudes in six domains: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. They reported good psychometric properties across a large sample of clinical areas in several countries, provided benchmarking data and noted research linking scores to clinical outcomes. Results are commonly reported as the percentage of respondents in a unit with positive attitudes in each domain, which makes it possible to compare units and track change. Westbrook will administer the survey to all clinical staff annually, report results by unit and discipline and share them with each unit, which will choose one domain to improve.

Interpreting the Results

Better measurement usually makes safety look worse at first. When the trigger tool is introduced, Westbrook's measured harm will rise sharply compared with incident reports, not because care has worsened but because more harm is being seen. Leaders were briefed in advance so they would not treat the rise as a crisis or a failure. Trigger tool results will be reported monthly as a run chart, with the understanding that twenty records a month produce considerable random variation and that trends over several months matter more than any single month. Year one is for building a trustworthy baseline; improvement targets will follow. Incident reports will continue, and their number rising, alongside stable or falling trigger tool harm, would be read as a sign of a stronger reporting culture.

Reliability and Limits of the Measures

Both measures have limits that the plan acknowledges. Trigger review depends on what is documented; harm that is never recorded, such as a delayed diagnosis discovered after discharge, may be missed. Reviewers can disagree about whether an event occurred or how severe it was, so the two nurse reviewers will independently review every fifth record and compare results each quarter, with discussion of disagreements to keep their judgments aligned. Culture surveys depend on response rates and honesty; a unit where staff fear retaliation may report good culture or not respond at all. Westbrook will aim for a response rate of at least 60% on every unit and will treat very low participation as a warning sign in itself. Neither measure is a performance ranking for individual managers, and results will be used for learning, which protects the honesty both methods depend on.

Using Results for Improvement

Each quarter, the patient safety committee will review the types of harm found by trigger review and select the most common or severe for focused improvement, as it did with hypoglycemia after the pilot. Culture survey results will be discussed with each unit, and units with low safety climate scores will receive support from the patient safety office. Results will also be reported to the board quality committee.

Conclusion

Counting incident reports told Westbrook how often staff reported harm, not how often patients were harmed. The Global Trigger Tool, which detected about ten times more harm than reporting in a national comparison, and the Safety Attitudes Questionnaire, with validated domains and benchmarks, give the hospital measures of outcomes and culture. Preparing leaders for rising numbers and using results to choose improvement priorities turn measurement into action.

References

Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., Whittington, J. C., Frankel, A., Seger, A., & James, B. C. (2011). 'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30(4), 581-589. https://doi.org/10.1377/hlthaff.2011.0190

Griffin, F. A., & Resar, R. K. (2009). IHI Global Trigger Tool for measuring adverse events (2nd ed.). Institute for Healthcare Improvement.

Sexton, J. B., Helmreich, R. L., Neilands, T. B., Rowan, K., Vella, K., Boyden, J., Roberts, P. R., & Thomas, E. J. (2006). The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Services Research, 6, Article 44. https://doi.org/10.1186/1472-6963-6-44