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

Table 2 Description, nature and known potential underlying causes for the missed AEs after review stage 2

Missed AEs by the HMPS method	Rejected as AE	Severity scale^a	Criteria number^b	Orthopaedic knowledge	Computerised record system knowledge	Time limit 20 minutes
Pressure ulcer		1	3			NA
Pain		1	1			NA
Infiltrated intravenous infusion		1	3			NA
Pressure ulcer		1	3			NA
Missed AEs by the GTT	Rejected as AE	Severity Scale ^c	Triggers C13 procedure” and/or C14 care: other”	Orthopaedic knowledge	Computerised record system knowledge	Time limit 20 minutes
Re-fracture		G		X		X
Urinary retention		E	X
Neurological harm		E	X	X	X
Wound infection		F			X
Wound infection		E			X
Pulmonary embolism		F
Infiltrated intravenous infusion		E	X
Infiltrated intravenous infusion		E	X
Urinary retention		E	X
Wound infection		F			X
Urinary retention		E	X
Discharge deficiencies		F
Urinary tract infection		F	X
Urinary retention		E	X
Urinary retention		E	X
Thrombophlebitis		E	X
Pressure ulcer		E
Late detection of fracture		F	X
Mistreated fracture		F	X	X
Wound during dressing		E	X			X
Urinary retention	X
External fixation, wound		E	X			X
Red skin from bandage		E	X
Fungus		E
Pressure ulcer		E
Urinary retention		E	X
Infiltrated intravenous infusion		E	X
Ad latus displaced fracture	X
Sensory loss		E	X	X
Overdose of drug		F	X
Heparin induced thrombocytopenia		E	X			X
Rash due to bandage		E	X
Pressure ulcer		E
Pressure ulcer		E
Wound infection		E
Rash due to drug		E	X
Bleeding during surgery	X
Increased liver enzymes	X
Subsidence of the femoral stem	X
Wrong operation performed initially		F
Urinary retention		E	X
Neurological harm		G	X	X
Bleeding when urinary catheter is removed		E	X			X

AE, adverse events; HMPS, “Harvard Medical Practice Study”; GTT,” Global Trigger Tool”; NA, Not Applicable for this method.
^a 1, minimal impairment, recovery within 1 month.
^b 1, the index admission was an unplanned admission related to previous healthcare management within 30 days; 3, hospital-incurred patient injury.
^c E, contributed to or resulted in temporary harm to the patient and required intervention; F, contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalisation; G, Contributed to or caused permanent patient harm.

ISSN: 1754-9493