Trigger Effectiveness

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Year:

Overall Totals:

Trigger Events:	890		Adverse Events [E level]:	149	41.6%
Adverse Events:	358	2.5	Adverse Events [F level]:	158	44.1%
Trigger Uncovered Adverse Event:	287	80.2%	Adverse Event [G level]:	18	5.0%
Adverse Event Without Trigger:	71	19.8%	Adverse Event [H level]:	0	0.0%
Sentinel Event:	51	14.2%	Adverse Event [I level]:	33	9.2%
Never Event:	…

ID	Trigger Event Name	T-	AE	TA	-A	E	F	G	I	SE
00	NoTrigger	246	0	0	0	0	0	0	0	0
C1	Transfusion or use of blood products	115	16	16	0	13	2	0	1	1
C3	Acute dialysis	4	3	3	0	0	2	0	1	1
C4	Positive blood culture	27	15	13	2	1	12	1	1	2
C5	X-ray or Doppler studies for emboli or DVT	4	3	2	1	1	2	0	0	0
C6	Decrease of greater than 25% in Hb or Hct	73	18	18	0	13	4	0	1	1
C7	Patient fall	8	4	4	0	3	1	0	0	0
C8	Pressure ulcers	71	61	61	0	45	16	0	0	0
C9	Readmission within 30 days	82	17	17	0	1	13	1	2	3
C10	Restraint use	54	3	3	0	3	0	0	0	0
C11	Healthcare-associated infection	69	64	30	34	7	51	1	5	6
C12	In-hospital stroke	32	4	4	0	0	1	3	0	3
C13	Transfer to higher level of care	43	11	11	0	0	6	2	3	5
C14	Any procedure complication	36	24	19	5	4	14	3	3	6
C15	Other	11	7	3	4	2	3	1	1	2
I1	Pneumonia onset	19	15	10	5	0	11	0	4	4
I2	Readmission to ICU	3	3	3	0	0	1	0	2	2
I3	In-unit procedure	3	2	2	0	1	0	0	1	1
I4	Intubation/reintubation	1	0	0	0	0	0	0	0	0
M2	PTT greater than 100 seconds	8	4	4	0	4	0	0	0	0
M4	Glucose less than 50 mg/dl	1	0	0	0	0	0	0	0	0
M5	Rising BUN or serum creatinine greater than 2 times baseline	20	6	6	0	1	2	0	3	3
M6	Vitamin K administration	40	7	7	0	4	2	1	0	1
M7	Benadryl (Diphenhydramine) use	50	13	13	0	13	0	0	0	0
M8	Romazicon (Flumazenil) use	4	3	3	0	2	0	0	1	1
M9	Naloxone (Narcan) use	1	1	1	0	1	0	0	0	0
M10	Anti-emetic use	6	2	2	0	2	0	0	0	0
M11	Over-sedation/hypotension	2	2	0	2	0	1	0	1	1
M12	Abrupt medication stop	36	24	14	10	21	1	2	0	2
M13	Other	2	2	1	1	2	0	0	0	0
S1	Return to surgery	15	8	8	0	0	8	0	0	0
S2	Change in procedure	1	0	0	0	0	0	0	0	0
S3	Admission to ICU post-op	4	0	0	0	0	0	0	0	0
S4	Intubation/reintubation/BiPap in PACU	3	3	0	3	0	2	1	0	1
S5	X-ray intra-op or in PACU	4	0	0	0	0	0	0	0	0
S6	Intra-op or post-op death	10	3	3	0	0	0	0	3	3
S7	Mechanical ventilation greater than 24 hrs post-op	5	3	0	3	0	2	1	0	1
S8	Intra-op epinephrine, nor-epinephrine, naloxone, or romazicon	7	1	1	0	1	0	0	0	0
S9	Post-op trophonin level greater than 1.5 ng/ml	3	1	1	0	0	0	1	0	1
S10	Change of anesthetic during surgery	2	2	2	0	2	0	0	0	0
S11	Consult requested in PACU	1	0	0	0	0	0	0	0	0
S14	Operative time greater than 6 hrs	10	3	2	1	2	1	0	0	0
		*890	358	287	71	149	158	18	33	51

Column Headings:
*: not including ID=00
ID: trigger code from IHI white paper i.e. [category]+[sequence number]
T-: total triggers
AE: total adverse events. {T/AE}%
TA: adverse events preceded by a positive trigger. {TA/AE}%
-A: adverse events NOT preceded by any trigger (found by browsing the chart). {-A/AE}%
E~I: level of harm in adverse events (as described in Merck protocol). {E~I/AE}%

Category E: Temporary harm to the patient and required intervention
Category F: Temporary harm to the patient and required initial or prolonged hospitalization
Category G: Permanent patient harm
Category H: Intervention required to sustain life
Category I: Patient death

SE: total sentinel events. {SE/AE}%
NE: total never events. {NE/AE}%

觸發事件分配：

不良事件傷害等級別分析：

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Article Information
Title:	Effectiveness of Single Trigger in Finding Adverse Events
Subtitle:	Effectiveness of Single Trigger in Finding Adverse Events
Author:
Article URL:	http://www.qi.org.tw/Safety/IHI/TrigAE.aspx
Created:	2010-06-12 15:29
Updated:	2011-04-13 08:52
Keywords:	Effectiveness of Single Trigger in Finding Adverse Events
Description:	Effectiveness of Single Trigger in Finding Adverse Events

Created: 2010-06-12 15:29
Updated: 2011-04-13 08:52

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Effectiveness of Single Trigger in Finding Adverse Events