In Denmark, first experiences with the GTT method were gained in a project by the Danish Cancer Society which aimed to assess the risks of hospitalized cancer patients in the country. The researchers used a combination of two methods: A GTT-based review of 527 patient records and analysis of patient safety events sent to the Danish Patient Safety Database (DPSD). They found that each method captured different types of adverse events and concluded that combination of different approaches is needed in order to get as full as possible a picture of causes of harm (Lipczak et al. 2011). A much larger project was undertaken in 2008 (Center for Quality, Region of Southern Denmark 2008) with hospital-level implementation and piloting of the tool. At that point, although 3 years had passed since the start of adverse event reporting to the DPSD, it was still not possible to assess the extent by which patient safety promotion efforts had actually resulted in a reduction of the number of patient injuries. The GTT was viewed as a validated tool that could be utilized to illustrate the extent of iatrogenic injuries. The Danish version of the method was produced through translation and adaptation to Danish conditions of the IHI original paper and its Swedish version (Center for Quality, Region Southern Denmark 2008). A clinical expert customized triggers to reflect more appropriately areas such as Danish laboratory values and clinical practices. A GTT learning kit was sent to all hospitals in January 2009. The project provided very useful insight in the practical aspects of using the tool (among others, composition of reviewing teams, training and statistical support) and also pointed out the need for continued validation and development of the method in the context of Nordic and broader international collaboration. More recently, in the framework of the Safer Hospital initiative, which is a collaboration between the Danish Society for Patient Safety, the Danish Regions, the TrygFonden Foundation and the IHI, targets of 15 % reduction in 30-day mortality and 30 % reduction in unintended harm (as measured by the GTT) were set. Five geographically distributed hospitals are participating to the initiative. As part of the quality strategy for 2011–2014, the Center for Quality in South Denmark made the decision to systematically apply the GTT in all hospital units. Presently, the GTT material is undergoing revision in collaboration between the Danish Society for Patient Safety and the Region of Southern Denmark.
Between 2008 and 2011, the IHI GTT classic method has been used as part of two hospitals’ patient safety projects (Hospital District of Southwest Finland and Vaasa Central Hospital). Severity and preventability of the identified adverse events have also been assessed. The intention is to continue with implementation of IHI’s GTT in different hospital departments. It is expected that using the methodology on the department level will produce more accurate and detailed information. However, this also requires the translation and validation of additional triggers related to, e.g., day surgery, pediatrics and psychiatry.
Pilots adapting the GTT in neurosurgery and NICU environments have been undertaken in the Tampere University Hospital (TAYS), accompanied by experimentation with data mining approaches (Öhman et al. 2011). Finally, there has been a preliminary assessment of the fitness of the national minimum data set for electronic health records to support such applications (Doupi et al. 2013).
In Norway, first experience with use of the GTT begun from Akershus hospital,Footnote 1 where the tool was combined with patient safety culture measurements. During the period of January–May 2007, the Akershus University Hospital’s Quality Department checked the records of a random sample of 481 patient records in four of the hospital’s departments using the IHI GTT method. (Deilkås and Hofoss 2008). Overall, in the period 2007–2010, 6,368 patient records (2,906 in the surgical and 3,462 records in the internal medicine department) were reviewed using the GTT (Svaar 2012). The results were used to promote improvement in the areas of hospital acquired infections, in conjunction with campaigns on hand hygiene and the introduction of the WHO Surgical Safety Checklist.
The national patient safety campaign
One of the missions of the campaign is to uncover the extent of patient harm in Norwegian health care. The first step is a national review of patient records in order to achieve an overview of patient harm in the country. Throughout the campaign, all hospital trusts will continue to conduct review of patient records using the GTT, as a means of detecting patient harm. The figures will be used to monitor the improvement of each individual healthcare provider organization, rather than compare hospitals (Norwegian Ministry of Health and Care Services 2011).
Preliminary results were reported in the fall of 2011 (In Safe Hands 2011) based on data submitted from 11 out of 19 health authorities, and the official report was published in December 2011, presenting the final results of the first year of national GTT use (Deilkås 2011). Eighteen out of 19 trusts and five private hospitals eventually submitted results. A total of 39 GTT teams reviewed the medical records from minimum 200 randomly selected hospital admissions of patients that had been discharged between March 1 and December 31, 2010. Records of 7,819 admissions were reviewed.
A total of 16 % of the hospital admissions included at least one adverse event (95 % CI 14–18 %; min 3.5 %–max 38 %).
A total of 7 % of the hospital admissions included at least one adverse event that led to prolonged hospitalization (95 % CI 6–9; min 2 %–max 18 %).
A total of 1 % of the hospital admissions included at least one adverse event that caused the patient permanent harm (95 % CI 0.8–1.4 %; min 0 %–max 3 %).
A total of 0.66 % of the hospital admissions involved patient harm that contributed to death (95 % CI 0.48–0.83 %; min 0 %–max 2 %).
A total of 9 % of the admissions involved an adverse event that led to prolonged hospitalization or more serious consequences (F to I categories) (95 % CI 7–10 %; min 2.5 %–max 21 %).
The procedure was repeated in 2011 (Delkås 2013). This time 47 GTT teams reviewed 240 admissions. All 19 health authorities participated, reviewing 9,808 admissions in total.
A total of 16 % of the hospital admissions included at least one adverse event (95 % CI 15–18 %; min 4 %–max 29 %).
A total of 9 % of the admissions involved an adverse event that led to prolonged hospitalization or more serious consequences (F to I categories) (95 % CI 8–10 %; min 2.1 %–max 19 %).
Trigger-type methodology was the basis of the 2008 retrospective record review of the National Board of Health, following on the steps of the Harvard Medical Practice Study and its subsequent modifications (Brennan et al. 1991). In addition to establishing the national rate of adverse events in hospitalized patients, a figure for the number of extra hospitalization days that had been necessary due to the avoidable injuries and the extra economic cost were also presented. Regarding the method itself, the researchers concluded that the criteria list would need to be revised if it should be suitable for clinical purpose use.
Piloting of medical record review with a translated version of the GTT method had begun already in 2005, in the hospitals of Östergötland, Kalmar and Jönköping counties. The efforts were fruitful. The three counties, in cooperation with the County Councils Mutual Insurance Company and SKL, published a Swedish handbook for GTT in 2008. The method has since then spread successively. In 2011, a survey showed that record review according to the GTT was being performed in at least one hospital per county, in 10 out of the 21 counties and regions in Sweden.
The Swedish version of the tool includes the evaluation of preventability of injuries (Swedish National Board of Health 2007). Even if a statement concerning preventability in the individual case is a matter of judgment by the review team and thus not completely reproducible, it has been seen to be of value for stimulation of critical self-appraisal in departments and hospitals. Assessment of preventability has the potential to both give a platform for preventive action and to improve the safety culture.
In 2010, the Swedish Government established a national patient safety initiative and made an agreement with the counties and regions to intensify efforts to increase patient safety. The agreement covers the years 2010–2014 and frames numerous goals where introduction of record review by GTT in all 65 hospitals has to be accomplished in 2012. For 2013, there will be a requirement of ongoing record reviewing on hospital level, but also introduction of record review on department level in those hospitals where that has not been done as yet. Formal training with the GTT method was given in the beginning of 2012 and all hospitals now have one or more teams for record review according to the GTT method. Follow-up meetings for further discussion of the method and for introduction of a new handbook took place during the autumn of 2012.
According to the national patient safety initiative, results from record review for the first 3 months in 2012 have been collected in a national data base and a figure on the level of injuries in non-psychiatric in-hospital care of adult patients has been calculated. Records of 3,900 admissions were reviewed. A total of 14 % of the hospital admissions included at least one adverse event. The most frequent adverse event was hospital acquired infections (39.5 %), of which the most common type was urinary tract infections. The complete study, published in November 2012, is available online (SKL 2012a, b). Data in the national database will be made available in detail to each participating hospital. At present, only figures concerning a mean value of level of injuries will be calculated on the national level. Data on preventability will neither be summarized, nor presented on national level for the time being.
A new Swedish handbook for trigger-based record review has been published during the autumn of 2012 (SKL 2012a, b). During 2011–2012, a project group evaluated the experiences from the first years of record reviewing to further develop the review process. Triggers have been evaluated, partly reformulated and guidance has been added to facilitate consideration on injuries and preventability with the aim of reducing variation in inter-rater reliability. Another aim has been to improve the efficiency in coverage of injuries in non-surgical health care. The potential of the method for use on hospital level in parallel to use on department level is described and the benefit of team work in the review process is stressed. Triggers covering neonatal, surgical and non-surgical care for children are under development and a handbook will be published in the beginning of 2013. Development of triggers covering primary care, outpatient care and psychiatry is under consideration.