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December 2018
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Triggering Management for Quality Improvement

The policy community has been concerned about medical errors since before the famous Institute of Medicine report, To Err Is Human. Concerns about medical errors have led to many efforts to improve the precision of estimates of these errors, with the concept of the Global Trigger Tool being the latest such effort. In the article by Kennerly et al. (2014), published in this issue of Health Services Research, an intentional search for medical errors in a large private hospital system with the Global Trigger Tool identified concerns at much higher rates than voluntary reporting (Kennerly found 61.4 adverse events per 1,000 patient days, with less than 5 percent of these events previously identified through voluntary adverse event reporting). Identification of adverse events through administrative claims was even lower.

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