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ture all ADEs. Nevertheless, we attempted to identify ADEs not
Trigger Tool to identify ADE is limited since it does not cap-
The present study has several limitations. The use of the
an automated method to monitor ADEs [24].
Eitan Israeli
characteristic of MPAL is independent of somatic genetic
in every aspect of the daily professional routine, which calls for
that the intratumoral immunophenotypic heterogeneity
the information technology development and its involvement
precursor acute lymphoblastic leukaemia. The authors showed
periodic in-depth survey by official regulators. Noteworthy is
in T/M MPAL, which shares genomic features with early T-cell
to the resources needed, but rather can be implemented as a
common in B/M MPAL, and biallelic WT1 alterations are common
not be applicable on a continuous basis in all hospitals due
(B/M), are genetically distinct. Rearrangement of ZNF384 is
infections). However, the Trigger Tool screening method may
two principal subtypes of MPAL, T/myeloid (T/M) and B/myeloid
together with other well-recognized measures (e.g., acquired
appropriate therapy. Alexander and colleagues showed that the
research design incorporated quality control and patient safety,
genetic characterization, and a lack of consensus regarding
different periods of times, and with a standardized method. This
of leukaemia with myeloid and lymphoid features, limited
ent hospitals within Israel as well as across other countries, over
Mixed phenotype acute leukaemia (MPAL) is a high-risk subtype
Trigger Tool for use in Israel is in the ability to compare differ-
The genetic basis and cell of origin of mixed phenotype acute leukaemia
The importance of this study in providing the validated
healthcare systems [23].
which improving patient safety can contribute to hospitals and
for preventable ADEs [5], and emphasizes the many ways in
adverse events, which are estimated to be as high as US$3511
sequence is another part of the additional costs associated with
between ADE rates and longer hospital stay [19,22]. This con-
previous studies, our study also demonstrated an association
daily regimens might further reduce ADE rates. Similar to
in which a potential mistake can take place and hence, simple
dose regimens expose hospitalized patients to more encounters
polypharmacy as a risk factor for adverse events [1]. Multiple
The subsequent modality of closure,
demonstrating similar associations with particular attention to
per day. These observations are consistent with previous studies
went an ADE were older and received more medication doses
Not surprisingly, patients in the current study who under-
might have also contributed to the low observed rates.
with computerized systems with alerts in cases of potential DDIs
were excluded. Furthermore, the use of electronic patient charts
cine and general surgery departments; therefore, both triggers
given the rarity of unfractionated heparin use in internal medi-
for benzodiazepine overdose and PTT monitoring is irrelevant
Coronary angiogram revealed a sub-
ADE = adverse drug events, N/A = not applicable
95% confidence interval
§
***Comparison excluding Britain
**Prevalence using Trigger tool only
*Including ADEs developing prior to admission
Number of ADEs per 100 admissions
Israel vs. other countries
Preventable ADE (%)
Positive predictive value (%)
Number of ADEs per 100 admissions
Percentage of patients with ADEs
Table 4. Comparison of adverse drug events among countries
A hypertensive 89 year old woman
IMAGING
ConferenCe preCedings Nature 2018; 562: 373 1988; 78: 361-8. closure of ventricular septal defects. Circulation Eurointervention 2016; 12: 94-102. closure: a systematic review of current evidence. post-myocardial infarction ventricular septal defect Heart J 2014; 35: 2060-8. myocardial infarction: a contemporary review. Eur Ventricular septal rupture complicating acute 19 (9): 547-52. with ST-elevation myocardial infarction. IMAJ 2017; and
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the student begins with the patient, continues with the patient pATIEnT InVOlVEMEnT: ADVAnTAgES AnD CHAllEngES Adverse Drug Event Rate in Israeli Hospitals: Validation
and ends his study with the patient, using books and lectures To end the conference, Prof. Karasik led a discussion regarding
as tools, as means to an end. For the junior student ... it is a safe the advantages and challenges in implementing patient involve- of an International Trigger Tool and an International
rule to have no teaching without a patient for the text, and the ment within the healthcare system. The main point to consider,
best teaching is that taught by the patient himself” [10]. as this trend grows and expands, is that to truly improve objec- Comparison Study
One example of having patients be involved in the design tive and subjective outcomes, involvement of patients should
of a study regarding treatment of diabetes is implemented be in partnership with healthcare providers. Eyal Zimlichman MD *, Itai Gueta MD *, Daniella Daliyot RN Msc , Amitai Ziv MD , Bernice Oberman Msc ,
1
2,7
1,7
3
1,7
by the newly established virtual clinic at the Sheba Medical Ohad Hochman MD , Ofer Tamir MD , Orna Tal MD and Ronen Loebstein MD 1,7
4,7
6,7
5,7
Center. Correspondence
Dr. V.M. Kalamaro 1 Management, Institute for Clinical Pharmacology and Toxicology and Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer,
3
2
Israeli Center for Research and Policy in Diabetes, Gertner Institute for Israel
pATIEnT InVOlVEMEnT: DESIgn Of A nEw HEAlTHCARE SERVICE Epidemiology and Health Policy Research, Sheba Medical Center, 4 Management, Hillel Yaffe Medical Center, Hadera, Israel
With the number of people diagnosed with type 1 diabetes Tel Hashomer 5265601, Israel 5 Management, Padeh Poria Medical Center, Tiberias, Israel
131118-COHANIM - 131118-COHANIM | 1 - B | 18-11-13 | 11:24:13 | SR:-- | Magenta
continuously growing, it is necessary that patients receive undi- email: vardit.kalamaro@gmail.com 6 Management, Assaf Harofeh Medical Center, Zerifin, Israel
131118-COHANIM - 131118-COHANIM | 1 - B | 18-11-13 | 11:24:13 | SR:-- | Yellow
#131118-COHANIM - 131118-COHANIM | 1 - B | 18-11-13 | 11:24:13 | SR:-- | Black
vided attention and high-quality care. Dr. Orly Tamir, the direc- References 7 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
131118-COHANIM - 131118-COHANIM | 1 - B | 18-11-13 | 11:24:13 | SR:-- | Cyan
tor of OTZMA Diabetes Care Initiative and the Israeli Center 1. Conference Program. The 4th Annual Conference on Therapeutic Patient
for Research and Policy in Diabetes at the Gertner Institute Education in Diabetes. OTZMA, 21 March 2018.
for Epidemiology and Health Policy Research, presented the 2. Légaré F, Stacey D, Turcotte S, et al. Interventions for improving the adoption of
shared decision making by healthcare professionals. Cochrane Database Syst Rev
need for a virtual clinic for adult type 1 diabetes patients. Tamir 2014; (9): CD006732.
described the unique needs of young adults who are dealing 3. Public Participation Team. Patient and Public Participation Policy. NHS dverse drug events (ADEs) are a major cause of morbidity
with type 1 diabetes and the shortfalls in the current provi- England. April 2017. [Available from https://www.england.nhs.uk/wp-content/ ABSTRACT: Background: Adverse drug events (ADEs) are a major cause A and mortality worldwide. It is estimated that 1 out 5 in-
uploads/2017/04/ppp-policy.pdf].
sion of care for this patient population. Many believe that a 4. Oliver SR. How can health services users contribute to the NHS research and of morbidity and mortality worldwide. Hence, identifying and hospital injuries or deaths are secondary to an ADE, with an
virtual clinic would provide a great value to patients and would development program? BMJ 1995; 310 (6990): 1318-20. monitoring ADEs is of utmost importance. The Trigger Tool annual prevalence of up to 450,000 injuries in the United States
improve adherence to recommended therapy. In the United 5. Perestelo-Perez L, Rivero-Santana A, Alvarez-Perez Y, Alonso-Coello P, Orrego introduced by the Institute of Healthcare Improvement in the [1,2]. Medication errors have been shown to be responsible for
Kingdom, a few virtual clinics have started trials. At London’s C, Serrano-Aguilar P. Shared decision making in Spain: supportive policies United States has been used in various countries worldwide, 20% of ADEs, of which 28% were defined as preventable [3,4].
and research initiatives, trends and directions for future. Z Evid Fortbild Qual
King’s College Hospital, 27,000 of their patients have type 1 Gesundhwes 2017; 123-124: 85-90. but has yet to be validated in Israel. The latter is further accompanied by extra costs of more than
diabetes but because of the size of this population, individu- 6. Richards T, Snow R, Schroter S. Editorials: Logging the BMJ’s “patient journey”. Objective: To validate the international Trigger Tool in Israel US$3000 per patient with a 3 day increase in hospital stay [5].
als cannot receive the medical attention they need. Through BMJ 2015; 351: h4396. and to compare the results with those generated in various In light of these findings, identifying and preventing ADEs
Skype or another virtual medium, the virtual clinic allots 20 7. Weldring T, Smith SM. Patient-Reported Outcomes (PROs) and Patient-Reported countries. when they do occur has been a cardinal role in ensuring patient
Outcome Measures (PROMs). Health Serv Insights. 2013; 6: 61-8.
minutes to each patient and provides them with a specialist 8. Black N. Patient reported outcome measures could help transform healthcare. Methods: A retrospective descriptive correlative analysis safety and reducing healthcare costs [6].
nurse or educator to discuss aspects of diabetes management, BMJ 2013; 346: f167. surveying four general hospitals in Israel from different The process of in-hospital drug administration is a multi-
geographical regions was conducted. Patient medical charts
such as blood glucose levels and insulin administration [11]. 9. Geissler J, Sharf G, et al. Factors influencing adherence in CML and ways to (n=960) were screened for 17 established triggers and disciplinary process usually involving the treating physician,
The design of the virtual clinic at the Sheba Medical Center is improvement: Results of a patient-driven survey of 2546 patients in 63 countries. confirmed for the presence of an ADE. Trigger incidence was nursing staff, and pharmacists. This process is associated with
J Cancer Res Clin Oncol 2017. 143: 1167-76.
conducted in collaboration with patient advisors. The ultimate 10. Fiddes PJ, Brooks PM, Komesaroff P. The patient is the teacher: ambulatory compared to the actual ADE rate. Further comparison among an inherent potential for errors and hence, precise communi-
goal is to achieve an automated remote follow-up that provides patient-centred student-based interprofessional education where the patient is the countries was conducted using published literature describing cation and highly efficient technologies are required for risk
notifications to the medical staff whenever the patient’s clinical teacher who improves patient care outcomes. Intern Med J 2013; 43 (7): 747-50. Trigger Tool validation in various countries. reduction. Among the technologies, computerized physician
values are out of the recommended range. Process evaluation 11. Woodfield J. Virtual clinics launched across UK to improve type 1 diabetes care. Results: A total of 421 triggers in 279 hospitalizations were order entry (CPOE) systems and electronic medication-admin-
2016 [Available from https://www.diabetes.co.uk/news/2016/mar/virtual-clinics-
and outcome evaluations are being assessed. launched-across-uk-to-improve-type-1-diabetes-care-94280693.html]. identified, of which 75 ADEs in 72 hospitalizations (7.5%) istration systems have been used to reduce prescription and
were confirmed. In addition, two ADEs were identified by chart transcription errors [7]. The former has been shown to reduce
Capsule review only. Mean positive predictive value was 17.81% and preventable ADEs by approximately one-third [8].
overall sensitivity was 97%. We found 1.54 ADEs for every Aside from prevention, identifying an ADE is crucial for
Interferon for bacterial infections 100 hospitalization days, 7.8 ADEs per 100 admissions, and risk assessment and institutional reasoning. Monitoring patient
1.81 ADEs for every 1000 doses of medication. Of the 77 ADEs files and voluntary staff reporting were demonstrated to be less
An early step in the host response to viral infection involves was sufficient in enhancing host control of infections with two identified, 22.7% were defined as preventable. thorough and more expensive [9]. In 2003, the Institute of
a burst of synthesis of type I interferons that allow cells to strains of gram-positive bacteria. Normal induction of Usp18 Conclusions: Our results support the Trigger Tool validity Healthcare Improvement (IHI) in the United States presented
quickly fight back against the offending viruses. Shaabani and after infection impaired antibacterial responses mediated in Israel as a standardized method. Further studies should the Trigger Tool for measuring ADEs [10]. The tool identifies
co-authors investigated how the same interferon-stimulated by tumor necrosis factor. Usp18 thus represents a potential evaluate between hospital and region differences in ADE rate, potential ADEs by well-defined clues present in patient records,
genes (ISGs) that usually help against viruses surprisingly therapeutic target for control of serious bacterial infections. in particular for the preventable events.
dampen the host’s ability to resist many bacterial infections. Sci Immunol 2018; 3: eaau2125 IMAJ 2018; 20: 665–669 namely triggers. By using this tool, pre-defined triggers are
Deletion of a single ISG called Usp18 in mouse dendritic cells Eitan Israeli KEY WORDS: adverse drug events (ADE), in-hospital drug administration, screened within the patient’s chart until they are found. This
procedure is followed by tracking the trigger retrospectively, a
PERFECTOR “we are what we pretend to be, so we must be careful what we pretend to be” *The first and second authors contributed equally to this study process that might reveal an ADE. Its low cost and rapid training
Israeli hospital care, Trigger Tool
requirements enabled its introduction in many hospitals in the
United States as well as in various European countries [11-18].
Kurt Vonnegut, (1922–2007), American novelist
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