Volume 49 | Number 5 | October 2014

Abstract List

Donald A. Kennerly M.D., Ph.D., Rustam Kudyakov M.D.,M.P.H., Briget Graca J.D., M.S., Margaret Saldaña R.H.I.A., M.P.H., Jan Compton R.N., B.S.N., M.S.H.A., C.P.H.Q., David Nicewander M.S., Richard Gilder M.S., R.N.‐B.C.


To report 5 years of adverse events (s) identified using an enhanced Global Trigger Tool () in a large health care system.

Study Setting

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

Study Design

We examined incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used ‐detection systems.

Data Collection

Professional nurse reviewers abstracted 9,017 records using the enhanced , recording triggers and s. Medical record/account numbers were matched to identify overlapping voluntary reports or Patient Safety Indicators (s).

Principal Findings

Estimated rates were as follows: 61.4 s/1,000 patient‐days, 38.1 s/100 discharges, and 32.1 percent of patients with ≥1 . Of 1,300 present‐on‐admission s (37.9 percent of total), 78.5 percent showed ‐ level F harm and 87.6 percent were “preventable/possibly preventable.” Of 2,129 hospital‐acquired s, 63.3 percent had level E harm, 70.8 percent were “preventable/possibly preventable”; the most common category was “surgical/procedural” (40.5 percent). Voluntary reports and s captured <5 percent of encounters with hospital‐acquired s.


s are common and potentially amenable to prevention. ‐identified s are seldom caught by commonly used ‐detection systems.