For the pilot test, which was conducted at Adventist Health System, nurses determined if harm had occurred by examining the EHRs of patients with positive triggers. The nurses grouped any identified harms into five categories and assigned a severity level. The harms were also labeled as hospital-acquired or outside-acquired.
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After implementing the harm trigger system, the data showed that a total of 2,696 harms occurred, of which almost one-third were acquired outside the hospital. Hypoglycemia was the most frequently identified harm. Additionally, nurse reviewers analyzed 20 records in 1.5 hours using the automated system. Comparatively, record analysis using the manual review process took 6.5 hours. The system also allowed Adventist Health System to identify harm patterns.
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