Adverse events toolkit. Clinical guidance for identifying harm
- Collection:
- Health Policy and Services Research
- Alternate Title(s):
- Clinical guidance for identifying harm
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- Washington, D.C. : U.S. Department of Health and Human Services, Office of Inspector General, July 2023
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Evaluation Studies as Topic Government Regulation Medical Errors Patient Harm Risk Management United States
- Genre(s):
- Technical Report
- Abstract:
- This toolkit resource provides details about how clinical experts assessed specific conditions and injuries related to common types of harm events while conducting our medical record reviews. It also includes information about the “triggers” (i.e., clinical clues of harm) our reviewers used to screen for possible harm events in hospitals. The toolkit describes the clinical guidance used in a recent report, Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018, OEI-06-18-00400, and builds upon a series of reports about adverse events in hospitals and other health care settings. Of the 18 reports currently in this series, 7 studies used nurses and physicians to review medical records to identify adverse events (each focused on a different health care setting). The goal of our medical record reviews was to establish a national, point-in-time rate of patient harm. This methodology builds on the Global Trigger Tool (GTT) methodology developed by the Institute for Healthcare Improvement (IHI) which we adapted and used for screening and flagging medical records for possible patient harm.1 A companion resource, Adverse Events Toolkit: Medical Record Review Methodology, details about our methodological approach and decision criteria. During the course of our reviews, we recorded internal decisions, researched clinical literature and guidelines, interviewed experts in various fields, and conducted routine calls to gain consensus among reviewers on decisions regarding what constitutes harm and how to categorize harm events. The “Specific Conditions and Injuries” section provides guidance on harm identification and categorization for 29 conditions encountered during our medical record reviews. These include conditions and injuries that were commonly found in our reviews and for which we provided specific guidance to our reviewers. As such, the list is not comprehensive of all types of patient harm events. The “Hospital Trigger Tool” section includes the triggers we used for flagging potential harm events in hospitals. We use triggers like clinical clues within the medical record that may indicate harm (e.g., abnormal laboratory values or falls). In addition, the Appendix in this resource include the trigger tool worksheets that reviewers used in different health care settings. The clinical information presented is current as of October 2018, our last adverse events medical record review. We did not reassess all clinical guidelines when drafting this toolkit. As such, users should seek out the most recent clinical guidance and standards of care and apply those to their adverse event determinations.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (78 pages))
- NLM Unique ID:
- 9918716086406676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918716086406676