An automated ED “trigger tool” helps clinicians identify the most important adverse event cases for chart review, according to the authors of a recent analysis.1

“This study was motivated by our observance of the very low yield of traditional approaches for detecting adverse events in the ED,” says Richard T. Griffey, MD, MPH, the study’s lead author.

The typical approach is to review all ED records that meet specific criteria: death within 24 hours of an ED visit, upgrades in care from the floor to an ICU, or return visits to the ED that resulted in the patient’s admission to the hospital.

“While there is no real gold standard for determining the true ED adverse event rate, trigger tools have demonstrated superior results for this purpose,” says Griffey, professor and associate chief of the department of emergency medicine at the Washington University School of Medicine in St. Louis.

Usually, a nurse screens a random selection of records for the presence of triggers that make it more likely an adverse event is present. From there, the nurse reviews only records with triggers for the presence of adverse events. Griffey and colleagues noted the Institute for Healthcare Improvement’s Global Trigger Tool contains only two triggers related to ED care. “That prompted our interest in developing a trigger tool specifically for the ED,” Griffey reports.

The researchers set out to develop a tool in which the triggers are based on observed associations with the presence of adverse events. They also wanted to make the most out of querying data from the electronic health record. “Our thought is that this might, in large part, replace the traditional review approach,” Griffey offers.

The patient safety movement emphasizes the need to focus on detecting harm — ideally, preventable harm — rather than just errors. Instead of remaining hidden, adverse events should be identified and shared.

“In this case, it is not that adverse events were being hidden, but rather that the tools for identifying adverse events are blunt, low-yield, and outdated,” Griffey explains.

The ED Trigger Tool (EDTT) is more efficient than other trigger tools to date, says Griffey, thanks to the automated screening for the presence of triggers.

For example, if a computer screening for the trigger “diphenhydramine administration” is positive, it is strongly associated with an occurrence of an allergic reaction. Rather than randomly selecting a small sample of records to screen for the presence of triggers, then reviewing those cases with triggers present, all records with triggers are identified for a designated period (e.g., the previous month).

“Then, we apply a filter of sorts to identify those visits at highest risk for adverse events based upon the number of triggers present and their weights, or strengths of association with adverse events,” Griffey reports.

A set of triggers (including vital signs, lab values, medications, orders, and procedures) identifies a much broader range of adverse event types than looking at all records that include one specific trigger (e.g., deaths within 24 hours).

“Using the EDTT to identify areas for improvement, we aim to improve patient safety, which could have a meaningful impact on liability,” Griffey says.


  1. Griffey RT, Schneider RM, Todorov AA. The emergency department trigger tool: A novel approach to screening for quality and safety events. Ann Emerg Med 2020;76:230-240.