Assessment of Adverse Events in End-Of-Life Care Using a Modified Global Trigger Tool: Evidence from Germany

Abstract

End-of-life care represents one of the most sensitive and complex areas of healthcare delivery. Patients receiving palliative and terminal care are vulnerable to adverse events due to advanced illness, polypharmacy, frequent transitions in care, and intensive symptom management interventions. Traditional patient safety tools often fail to adequately capture the unique harms experienced in palliative settings because deterioration and death may occur naturally as part of disease progression. This study examines the effectiveness of a Modified Global Trigger Tool (MGTT) in identifying adverse events among end-of-life patients in Germany. A retrospective record review was conducted using 320 patient records collected from palliative care units, hospice centers, and tertiary hospitals across Germany between 2023 and 2025. The modified trigger tool incorporated specialized triggers related to symptom burden, medication toxicity, communication failures, delayed comfort care interventions, overtreatment, and disturbed dying processes. Data were analyzed using descriptive statistical techniques and comparative adverse event categorization. The findings revealed that 61.8% of reviewed patient records contained at least one trigger, while 34.7% demonstrated identifiable adverse events. Medication-related harms, delayed symptom management, diagnostic overtreatment, and communication breakdowns were among the most frequently observed safety concerns. The study highlights the importance of adapting conventional patient safety frameworks to the realities of palliative and end-of-life care. The Modified Global Trigger Tool demonstrated improved sensitivity for identifying clinically relevant harms unique to terminally ill populations. The study concludes that systematic adverse event monitoring in end-of-life care can improve patient dignity, symptom relief, interdisciplinary coordination, and quality of dying. Adoption of modified trigger-based surveillance systems may strengthen patient safety initiatives within German palliative healthcare institutions.

KEYWORDS: End-of-life care, palliative care, adverse events, modified global trigger tool, patient safety, Germany, hospice care, symptom management, healthcare quality, terminal care