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Table 1 An overview of the origins of the “Harvard Medical Practice Study” method and the “Global Trigger Tool”

From: Is detection of adverse events affected by record review methodology? an evaluation of the “Harvard Medical Practice Study” method and the “Global Trigger Tool”

Origin and perspective Definition/inclusion and method of review Review stage 1 Review stage 2 Criterion/trigger Sample size and time frame for inclusion
“Harvard Medical Practice Study” (HMPS)[1, 16, 17] with subsequent modifications [26, 18, 19] An unintended injury or complication that results in disability at discharge, death or prolonged hospital stay and is caused by healthcare management rather than the patient’s underlying disease Generally one reviewer per record Mostly two physician reviewers per record General for both methods: Random, big samples to measure the incidence and to generalise the result
Medicolegal and focus on negligence the first studies and thereafter quality improvement and preventability perspective Includes both omission and commission Screening for one of 18 criteria by trained nurses (can be other professionals) Detailed independent review An indication that patient harm may have occurred An AE had to have occurred before and during and detected during and/or after index admission
  Adult, inpatients, often exclusion of e.g. psychiatric and rehabilitation patients Comprehensive reading Assess the AE by using different scales according to e.g. causation, severity, preventability, timing, causes, and types Directs the medical reviewer to relevant parts of the records by the notes  
   No assessment, generally only registration of found criteria, description of the potential AE, and a brief summary of the admission Generally includes only one AE per patient i.e. the most severe Some criteria/triggers are AEs by definition e.g. healthcare-associated infections Different inclusion periods before and after index admission
Research method Two [1, 2] - three [6, 18] stage retrospective record review No time limit No time limit Positive criteria/triggers may be without connection to patient harm i.e. false positive  
     HMPS method:  
     18 broad criteria  
“Global Trigger Tool”[7] Unintended injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalisation, or that results in death Two reviewers per record The team discuss the findings together 54 triggers, mostly narrow Random, small samples sufficient for the design of safety work over time
Quality improvement tool for clinical practice Includes commission, excludes omission First screening independently for one of 54 triggers by trained nurses (can be other professionals), focus on triggers, no comprehensive reading, reads just relevant parts related to found triggers; second, consensus One physician, who does not generally review the record but does authenticate the consensus findings of the AEs, the severity rating, and answer questions from reviewers in review stage 1 The Swedish version [20] contains 53 triggers, the triggers “restraint use” in the care module and “other” in the medication module were excluded, and a trigger, “occurrence of any postoperative complication“, was added in the surgical module 10 records every second week or 20 records every month per hospital
Track AE rate over time in a hospital or a clinic Adult, inpatients, exclusion of psychiatric and rehabilitation patients Finds triggers, describes the potential AE, and categorise harm according to NCC MERP index [21] The physician is the final arbitrator   Length of stay at least 24 hours
  Two stage retrospective record review No assessment of preventability All identified AEs are included   An AE had to have occurred before and during and detected during and/or after index admission
   Maximum 20 minutes per record No time limit   30 days inclusion period before and after index admission
    The Swedish version includes the same preventability scale as used in HMPS methodology [2, 20]   
  1. AE, adverse event; NCC MERP, National Coordination Council for Medication Error Reporting and Prevention (NCC MERP) index [21]. Category A-D describes risk and no harm incident. Category E-I describes harm.