Measuring Harm in Hospitalized Children via a Trigger Tool

Thursday, 27 July 2017: 4:50 PM

Lya Stroupe, DNP
Nursing Administration, West Virginia University Medicine, Morgantown, WV, USA


To use the Global Assessment of Pediatric Patient Safety (GAPPS) tool to detect adverse events in a pediatric inpatient setting of an academic medical center children’s hospital and compare to internal incident reporting methods.


Nurse reviewers used the GAPPS tool during a retrospective chart review of 100 patients discharged from the children’s hospital. Among the total 100 cases, 20 adverse events were discovered with the tool. Adverse events were validated by physician reviewers and the severity of harm and preventability were assigned. The number of adverse events were then compared to internal incident reporting for the same time frame.


The detection rate is 4.87% within 411 patient-days. In contrast, the hospital had only 1.22% incident reports.

Characteristics of patients include medical records from 100 patients discharged from a children's hospital on a general pediatrics floor. Out of the 100 cases reviewed, 20 adverse events were discovered with the GAPPS tool. A total of 45 triggers were identified in the 100 patients. The mean rate of triggers per patient is 0.45. Ten patients had one adverse event and 4 patients had two or three adverse events during their hospitalization period. The detection rate is 4.87% within 411 patient-days. In contrast, the hospital had only 1.22% incident reports (147 cases in 12005 patient-days) in 2014. Patients experienced adverse events had significantly longer average length of stay in hospital and higher mortality rate (p< 0.01). In addition, the distribution of hospital service at admission is significantly different in the two groups (p = 0.05): patients who had adverse events were less likely to be admitted as general medicine (21.43% vs. 45.35%) but more likely in intensive care (14.29% vs. 4.65%), compared to patients who didn’t have adverse events. The distribution of discharge disposition of the patients with adverse events was that 78.57% of them were discharged to home and one of them was deceased.

Characteristics of the adverse events shows that there is a significant difference between the two (triggers by the GAPPS tool and adverse events by hospital incidence reports) (p < 0.01): the triggers detected by GAPPS tool were distributed almost evenly in medications/fluids, hospital care environment, hospital acquired infections and hospital transfers/outcomes; while nearly half of the adverse events reported by the hospital were concentrated in medications/fluids, and more than a third of them were not related to the six categories.

Among the 20 adverse events, 9 (45%) of them are not preventable, while 11 (55%) of them are preventable. Because there are 4 patients who had multiple adverse events, a total number of 74 triggers were identified among all adverse events.

Conclusion:  This is the first study that compares two methods for detecting adverse events in hosptialized children. The GAPPS tool can detect 4 times more adverse events than the hospital incident reporting system. The results are likely to be replicated for other children’s hospitals to increase identification of adverse events and harm to patients. In our study we found 20 AEs(Adverse Events) per 100 patient and 48.66 AEs per 1000 patient-days. This is about 2-3 times higher than some of the trigger tools methods, where an ADE-only trigger tool was used.

Implementing the GAPPS triggers in EHRs will improve the usability and would also help concurrent detection of adverse events and preventing harm occurrences. The GAPPS study developed an automated version of 30 trigger tools. Future research will help in the refinement of the use of triggers in EHRs and to expand their use to include complex triggers to make it more usable and sustainable.