Assessment of The "IHI Global Trigger Tool" Reliability: New Perspectives From A Brazilian Study.

Research paper by Sara Monteiro SM Moraes, Teresa Cristina Abreu TCA Ferrari, Natália Mansur Pimentel NMP Figueiredo, Thaís Novaes Costa TNC Almeida, Caio César Lôbo CCL Sampaio, Yane Cristine Pereira YCP Andrade, Regina Oliveira RO Benedito, Alline Maria AM Beleigoli

Indexed on: 08 Mar '21Published on: 07 Mar '21Published in: International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua


The Institute for Healthcare Improvement Global Trigger Tool (IHI-GTT) is a simple and inexpensive method to identify adverse events (AEs) through retrospective search of triggers in medical records. Despite its large adoption in Brazilian hospitals, the reliability of the method has not been investigated locally. Moreover, availability of human resources might be a barrier to its implementation in low-resourced systems. The objective of this study was to evaluate the interrater reliability of an adapted version of IHI-GTT and compare it between nurses and medical students as primary reviewers in a hospital in Brazil. Two 4th-5th year-medical students and two experienced nurses applied GTT to a sample of 220 medical records randomly selected from 1,172 hospital admissions of adults (≥18 years) from Oct-Nov, 2016. Ability to identify AE was compared between pairs and against medical reviewer through percentage inter-examiner agreement and Kappa coefficient (K). Two outcomes - "AE identification" and "category of harm" - were evaluated according to two different denominators - "admissions" (the total number of admissions evaluated in the sample; reflects the presence or not of at least one AE in each admission) and "all possibilities of agreement" (obtained by adding each identified AE to the admissions without events; allows agreement assessment to be performed for each AE individually). Were identified 199 adverse events in 90 hospitalizations, with rates of 40.9% of admissions with AEs, 76.1 AEs/1,000 patient-days and 90.5 AEs/100 admissions. Comparing student-pair and nurse-pair, we found K=0.76 (95%IC 0.62-0.88) and K=0.17 (95%IC 0.06-0.27) for "AE identification" outcome and K=0.28 (95%IC 0.01-0.55) and K=0.46 (95%IC 0.28-0.64) for "category of harm" outcome to denominators "admission" and "all possibilities of agreement", respectively. There was no significant difference between the performances of the different primary reviewers composed in any analyses. IHI-GTT reliability varies considerably depending on the denominator used to calculate agreement. As the purpose of the tool is, in addition to measuring, promoting opportunities for quality of care improvement, the individual analysis of the AEs seems more appropriate. Further studies are needed to assess the implications of the slight agreement reached among primary reviewers on the test's overall accuracy. Moreover, advanced medical students may be considered for primary review in settings where unavailability of staff is a barrier to IHI-GTT adoption. © The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.