Table 3.
Trigger descriptors, AE and positive predictive value
| Trigger Code | Trigger description | Adverse events | Positive triggers | Severity of harm |
Trigger PPV (%) | ||||
|---|---|---|---|---|---|---|---|---|---|
| E | F | G | H | I | |||||
| PG8 | Complication of procedure or treatment | 182 | 257 | 99 | 63 | 6 | 11 | 3 | 70.8 |
| PG3 | Readmission to hospital within 30 days | 107 | 462 | 36 | 68 | 0 | 1 | 2 | 23.2 |
| PG2 | Tissue damage or pressure ulcer | 81 | 250 | 66 | 12 | 0 | 1 | 2 | 32.4 |
| PG4 | Unplanned admission | 68 | 1668 | 23 | 41 | 0 | 3 | 1 | 4.1 |
| PO1 | Other (specify) | 60 | 425 | 48 | 10 | 0 | 1 | 1 | 14.1 |
| PS3 | Surgical site infection | 48 | 60 | 24 | 22 | 0 | 1 | 1 | 80.0 |
| PM5 | Anti-emetic given | 41 | 507 | 40 | 1 | 0 | 0 | 0 | 8.1 |
| PG10 | Hypoxia O2 sat <85% | 36 | 157 | 31 | 2 | 3 | 0 | 0 | 22.9 |
| PG1 | EWS or baseline observations missing/incomplete or score/observation requiring response | 35 | 1362 | 26 | 8 | 0 | 1 | 0 | 2.6 |
| PG9 | Transfer to higher level of care (inc admission to specialist unit, ICU/HDU) | 35 | 273 | 15 | 14 | 0 | 5 | 1 | 12.8 |
| PS1 | Return to theatre | 33 | 75 | 15 | 15 | 2 | 1 | 44.0 | |
| PM7 | Intravenous bolus≥10 mL/kg colloid or crystalloid given | 31 | 386 | 22 | 5 | 1 | 1 | 2 | 8.0 |
| PG11 | Cancelled elective procedure/ delayed discharge | 24 | 55 | 10 | 12 | 1 | 0 | 1 | 43.6 |
| PL14 | Positive blood culture | 23 | 55 | 18 | 4 | 0 | 1 | 0 | 41.8 |
| PL13 | Nosocomial pneumonia | 21 | 28 | 8 | 10 | 0 | 2 | 1 | 75.0 |
| PL5 | Na+ <130 or >150 | 14 | 71 | 12 | 1 | 0 | 1 | 0 | 19.7 |
| PG5 | Cranial imaging | 10 | 141 | 4 | 2 | 3 | 0 | 1 | 7.0 |
| PL8 | Hyperglycaemia (>12 mmol/L) | 11 | 65 | 10 | 1 | 0 | 0 | 0 | 16.9 |
| PS2 | Change in planned procedure | 11 | 37 | 6 | 5 | 0 | 0 | 0 | 29.7 |
| PL3 | Abrupt drop in Hb or Hct (>25%) | 10 | 65 | 9 | 1 | 0 | 0 | 0 | 15.4 |
| PM8 | Abrupt medication stop | 10 | 52 | 8 | 2 | 0 | 0 | 0 | 19.2 |
| PL8 | Hypoglycaemia (<3 mmol/L) | 10 | 46 | 9 | 1 | 0 | 0 | 0 | 21.7 |
| PL9 | Drug level out of range | 10 | 32 | 8 | 2 | 0 | 0 | 0 | 31.3 |
| PL6 | K+ <3.0 or >6.0 | 9 | 69 | 8 | 0 | 0 | 1 | 0 | 13.0 |
| IP1 | Readmission to ICU or HDU | 9 | 16 | 5 | 1 | 0 | 3 | 0 | 56.3 |
| PS4 | Removal/injury or repair of organ | 9 | 43 | 3 | 5 | 1 | 0 | 0 | 20.9 |
| PG6 | Respiratory/cardiac arrest/crash call | 9 | 41 | 0 | 2 | 0 | 7 | 0 | 22.0 |
| PM5 | Chlorpheniramine given | 9 | 82 | 7 | 2 | 0 | 0 | 0 | 11.0 |
| PL2 | Transfusion | 8 | 143 | 6 | 1 | 0 | 1 | 0 | 5.6 |
| PL4 | Rising urea or creatinine (>2× baseline) | 6 | 54 | 4 | 2 | 0 | 0 | 0 | 11.1 |
| PL15 | Thrombocytopenia | 6 | 54 | 4 | 1 | 0 | 0 | 1 | 11.1 |
| PL1 | High INR (>5) or APTT>100 s | 6 | 31 | 6 | 0 | 0 | 0 | 0 | 19.4 |
| PM4 | Glucagon or glucose≥10% given | 6 | 50 | 6 | 0 | 0 | 0 | 0 | 12.0 |
| PG7 | Diagnostic imaging for embolus/thrombus +/− confirmation | 4 | 24 | 2 | 1 | 1 | 0 | 0 | 16.7 |
| PM2 | Naloxone given | 4 | 16 | 3 | 0 | 0 | 1 | 0 | 25.0 |
| PL11 | Clostridium difficile | 4 | 12 | 3 | 1 | 0 | 0 | 0 | 33.3 |
| PM1 | Vitamin K given (except routine neonatal dose) | 1 | 33 | 1 | 0 | 0 | 0 | 0 | 3.0 |
| PM3 | Flumazanil given | 0 | 2 | 0 | 0 | 0 | 0 | 0 | NA |
| PL10 | MRSA bacteraemia | 0 | 0 | 0 | 0 | 0 | 0 | 0 | NA |
| PL12 | Vancomycin-resistant enterococcus | 0 | 0 | 0 | 0 | 0 | 0 | 0 | NA |
| TOTAL | 1001 | 7199 | 605 | 318 | 18 | 43 | 17 | ||
AE, adverse events; APTT, activated partial thromboplastin time; Hb, haemoglobin; Hct, haematocrit; HDC, high dependency unit; ICU, intensive care unit; INR, international normalised ratio; MRSA, methicillin-resistant Staphylococcus aureu; NA, not applicable; PPV, positive predictive value.