Development of a Trigger Tool to Identify Adverse Events and No-Harm Incidents in Paediatric Oncology: A Modified Delphi Process Using Expert Knowledge and User Experiences

Charlotte Engvall^1,2*Margaretha Stenmarker^1,2,3Ann-Christine Andersson^4,5Axel Ros^4,6Maria Unbeck^7,8

• ¹Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
• ²Department of Pediatrics, Region Jonkopings lan, Jönköping, Sweden
• ³Department of Pediatrics, Institute of Clinical Sciences, Goteborgs universitet Sahlgrenska Akademin, Gothenburg, Sweden
• ⁴Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jonkoping University, Jönköping, Sweden
• ⁵The Child and Health Care Service, Region Jonkopings lan, Jönköping, Sweden
• ⁶Futurum - the Academy for Health and Care, Region Jonkopings lan, Jönköping, Sweden
• ⁷School of Health and Welfare, Hogskolan Dalarna, Falun, Sweden
• ⁸Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden

Background The objective of this study was to develop a Paediatric Oncology Trigger Tool aimed at facilitating the detection of adverse events and no-harm incidents in the patient process from specialised hospital care to home healthcare in paediatric oncology. The development of the trigger tool addresses the need for enhanced safety knowledge in paediatric oncology, particularly as the field has increasingly transitioned from inpatient admissions to day care and home healthcare settings. Existing trigger tools do not fully meet the specific requirements of paediatric oncology, where care is collaboratively provided by patients, parents and healthcare professionals. Materials and methods The study employed a multi-step process, including a literature search, a three-phase modified Delphi process, and the practical application of the trigger tool. All six Swedish paediatric oncology centres were represented in the Delphi process. Medical records were reviewed as part of the national multicentre study Patient Safety in Paediatric Oncology, which included participation from four out of six paediatric oncology centres, covering 64% of the population in Sweden. Data were collected from stakeholders representing the patient process from specialised hospital care to home healthcare in paediatric oncology, as well as from reviewers of medical records, and representatives with patient safety and trigger tool methodology expertise. Data were gathered through virtual meetings and web-based surveys, where the triggers were discussed and rated in terms of clinical relevance, comprehensibility and usefulness. Ratings were made using a four-point Likert scale. A dichotomisation process was used to assess consensus, defined as the proportion of respondents giving the same dichotomised rating. Result The key outcome was the development of a Paediatric Oncology Trigger Tool. The final tool consisted of 22 triggers with definitions and decision support information, designed to enhance understanding of patient safety in paediatric oncology. Conclusions The application of a multi-step development process resulted in a final context-specific trigger tool, the Paediatric Oncology Trigger Tool, addressing unique patient safety needs. The tool can be used in local safety initiatives aiming to improve safety for children with cancer. Additionally, this paper provides a transparent description of a systematic development process.