The Institute for Healthcare Improvement (IHI) Global Trigger Tool methodology is a straightforward yet powerful approach designed to accurately identify adverse events, also known as patient harm, and to measure their occurrence rates over time within healthcare settings. By consistently tracking these adverse events, healthcare organizations can effectively gauge whether implemented changes are genuinely enhancing the safety of their care delivery processes.
At the heart of the IHI Global Trigger Tool lies the use of “triggers,” or specific clues embedded within patient records, which act as indicators of potential adverse events (AEs). This trigger-based methodology offers an efficient way to assess the overall level of harm experienced by patients within a healthcare organization. The IHI Global Trigger Tool provides comprehensive guidance on training reviewers in this methodology and on conducting thorough retrospective reviews of patient records. These reviews utilize the identified triggers to pinpoint possible AEs that may have occurred. The tool itself includes a curated list of established AE triggers, detailed instructions for selecting appropriate patient records for review, training materials to ensure consistent application of the methodology, and helpful appendices containing references and frequently asked questions. Crucially, the IHI Global Trigger Tool provides the necessary instructions and standardized forms for collecting essential data, enabling healthcare providers to track three key performance measures:
- Adverse Events per 1,000 Patient Days
- Adverse Events per 100 Admissions
- Percentage of Admissions with an Adverse Event
This standardized approach allows for consistent monitoring and comparison of adverse event rates, facilitating data-driven improvements in patient safety.
Traditional methods of adverse event detection often rely on voluntary reporting systems and error tracking. However, research in public health has consistently shown that voluntary reporting captures only a fraction of actual errors, estimated to be between 10 and 20 percent. Furthermore, a significant majority of these reported errors, around 90 to 95 percent, do not result in actual harm to patients. This highlights the need for a more robust and effective method to identify events that truly cause patient harm. By quantifying both the extent and severity of harm, healthcare organizations can strategically select and implement targeted changes aimed at reducing patient harm more effectively. The Institute for Healthcare Improvement Global Trigger Tool methodology directly addresses this need.
Numerous hospitals have successfully adopted the IHI Global Trigger Tool to identify adverse events within their institutions. Beyond identification, the tool also facilitates measuring the level of harm associated with each adverse event and pinpointing specific areas within the organization where improvements are most needed. It is important to understand that the IHI Global Trigger Tool is intentionally designed as a sampling methodology and is not intended to detect every single adverse event in every patient record. The recommended time limitations for record review, coupled with the random selection of patient records, are carefully designed to provide a representative sample. This sampling approach yields data that is statistically sufficient for designing and guiding patient safety improvement initiatives within a hospital setting.
The origins of the IHI Global Trigger Tool can be traced back to May 2000, when the Institute for Healthcare Improvement (IHI) established the Idealized Design of the Medication System (IDMS) Group. This multidisciplinary group, comprising 30 physicians, pharmacists, nurses, statisticians, and other healthcare professionals, was tasked with the ambitious goal of designing a medication system that was tenfold safer and more cost-effective than existing systems. The Trigger Tool for Measuring Adverse Drug Events was the initial outcome of this group’s work, laying the groundwork for the subsequent development of the IHI Global Trigger Tool.
Since its initial development in late 2003, the adoption of the IHI Global Trigger Tool methodology has expanded significantly. Starting from collaborative projects, its use has spread to large-scale improvement initiatives, most notably including IHI’s widespread 5 Million Lives Campaign. The IHI Global Trigger Tool has become an indispensable tool for hundreds of hospitals across numerous countries. These institutions utilize it to continuously monitor their adverse event rates while actively working to improve patient safety protocols and outcomes. In 2008, the US Department of Health and Human Services Office of Inspector General conducted a pilot study focused on measuring adverse events among Medicare beneficiaries. In this study, the IHI Global Trigger Tool was selected and utilized as one of the primary methods for adverse event detection. This extensive and varied application of the IHI Global Trigger Tool has provided invaluable opportunities to gather feedback from a wide range of users. This feedback has been instrumental in identifying areas for clarification, refining definitions, and updating the tool’s materials to ensure its continued effectiveness and relevance in the evolving landscape of healthcare quality improvement.
How to Cite This Paper: Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. (Available at ihi.org)
