Development of a Trigger Tool to Identify Adverse Events and Harm in a Neuropsychiatry Setting
Authors: Sharma Sangeeta , Kapoor Kaveri , Nasare Namita , Bhardhwaj Ankit , Kushwaha Suman 
Published: September 2020

Background & Objectives
Adverse drug events (ADEs) present the greatest risk of harm to patients in hospitals, especially those receiving neuropsychiatric treatment. The objective of the present record-based study was to test the appropriateness of the neuropsychiatry trigger tool (NPTT) to identify and measure harm due to adverse events (AEs).

Methods
A total of 1324 clinical case notes of discharged patients from 2017 to 2018 with a hospital stay >24 hours to <70 days were examined.

Results
One hundred forty-four (10.88%) patients experienced 166 AEs. A total of 854 triggers (range, 1–12 triggers per patient) were identified in 296 (22.36%) and 39 (2.94%) patients presented with triggers at admission. The overall AE rate per 1000 patient days was 12.73 (intensive care unit, 21; inpatient department, 11.54). Triggers at admission were altered sensorium and abnormal behavior followed by headache, ataxia, and aspiration pneumonia. A small number of triggers accounted for most AEs (laxative, rising liver function test (LFT), hypokalemia, hyponatremia, health care–associated infections, intubation, abnormal behavior/sensorium, hepatic encephalopathy, antiemetics), although type of AE reported differed by level of care. Most AEs caused minor harm, and relatively fewer patients experienced temporary harm requiring intervention (110; 8.29%), permanent harm (45; 3.39%), harm requiring initial/prolonged hospitalization (10; 0.75%), interventions to sustain life (24; 1.81%), and death (109; 8%). The higher the number of AEs, the longer was the length of stay (average increased from 9.32 to 17.33 days). The NPTT identified 30 times more AEs compared with 5 AEs reported by voluntary method. Medication-related ADEs were found in 130 (90%) of 144 patients who experienced AEs. Antitubercular drugs caused most ameliorable AEs (visual disturbance, drug-induced vomiting, deranged LFT, constipation). Care is needed in attributing harm because some triggers (abnormal sensorium/behavior, intubation, headache/dizziness, laxatives) may overlap with neurological illnesses (cerebrovascular accident [CVA]/meningitis/stroke). If the triggers are identified early, harm/discomfort to the patients can be reduced. The NPTT can be used in patient safety improvement projects. Harm occurred in 296 (22.28%) patients (temporary, 120 [9%]; permanent, 178 [13%]). Adverse events prolonged hospital stay (14.29 days) compared with 9.32 days in patients without AEs.

Conclusions
A higher number of triggers per patient (≥5), trigger nature (intubation, cardiac arrest/shock), or the presenting illness (CVA/neuroinfections/status epilepticus/prolonged seizures) were correlated with the highest harm, that is, death. Because some triggers (abnormal sensorium/behavior, headache/dizziness, laxatives, intubation) may overlap with neurological illness (CVA/meningitis/stroke), care is needed in attributing harm. The NPTT identified 30 times more AEs compared with 5 AEs reported by voluntary method. Antitubercular drugs caused ameliorable AEs (visual disturbance, drug-induced vomiting, deranged LFT, constipation) and, if identified early, can reduce harm/discomfort to the patients.