Trigger Tool Dr Lisa Eskildsen Nov 2017

Provides GP teams with opportunities to identify Patient safety incidents Individual and team learning needs Relevant focus for improvement activity Ways to improve patient experience Provides GP teams with opportunities to identify

Finding patient safety incidents Simple checklist to rapidly screen small samples of high risk patient groups Uses TRIGGERS or “flags” to identify patients where harm may have occurred Structured in-depth review of notes looking for patient safety incidents Finding patient safety incidents

Patient Safety Incident Harm or potential harm “Any incident that caused harm, or could have caused harm to a patient as a result of their interaction with health care” (Scottish Guide)

Focus: Avoidable harm or potential harm Systems of care Minimising recurrence Focus:

Systems issues behind individual error Avoidable harm or potential harm Systems of care Minimising recurrence Focus: Systems issues behind individual error

Trigger Tool Process 1 2 3 Planning and preparation Reviewing random selection of records 2 Reflection and further action 3

1. Planning and preparation Who will be involved? How will you share the findings? System improvement not accountability Processes for managing event if serious harm has occurred Practice Improvement Activity (Audit) for Cornerstone 1. Planning and preparation

1. Planning and preparation PRACTICE MEETING Who will be involved? How will you share the findings? System improvement not accountability Processes for managing event if serious harm has occurred Practice Improvement Activity (Audit) for Cornerstone 1. Planning and preparation PRACTICE MEETING

Choose a cohort of patients that might be of higher risk Residential care Aged over 75 and on 6 or more medications Multiple hospital admissions Palliative care At risk individuals CKD, COPD, diabetes, CHF, CVD, Stroke/TIA Patients with one or more long term conditions Insulin, opiates, warfarin, NSAID, diuretics Patients on high risk medications Choose a cohort of patients that might be of higher risk These are examples to get you started There is no single ‘right’ group Each practice should determine the cohort they wish to review

Choose a cohort of patients that might be of higher risk Residential care Aged over 75 and on 6 or more medications Multiple hospital admissions Palliative care At risk individuals CKD, COPD, diabetes, CHF, CVD, Stroke/TIA Patients with one or more long term conditions Insulin, opiates, warfarin, NSAID, diuretics Patients on high risk medications Choose a cohort of patients that might be of higher risk These are examples to get you started There is no single ‘right’ group Each practice should determine the cohort they wish to review

Choose a cohort of patients that might be of higher risk Residential care Aged over 75 and on 6 or more medications Multiple hospital admissions Palliative care At risk individuals CKD, COPD, diabetes, CHF, CVD, Stroke/TIA Patients with one or more long term conditions Insulin, opiates, warfarin, NSAID, diuretics Patients on high risk medications Choose a cohort of patients that might be of higher risk These are examples to get you started There is no single ‘right’ group Each practice should determine the cohort they wish to review

Choose a cohort of patients that might be of higher risk Residential care Aged over 75 and on 6 or more medications Multiple hospital admissions Palliative care At risk individuals CKD, COPD, diabetes, CHF, CVD, Stroke/TIA Patients with one or more long term conditions Insulin, opiates, warfarin, NSAID, diuretics Patients on high risk medications Choose a cohort of patients that might be of higher risk These are examples to get you started There is no single ‘right’ group Each practice should determine the cohort they wish to review

Choose a cohort of patients that might be of higher risk Residential care Aged over 75 and on 6 or more medications Multiple hospital admissions Palliative care At risk individuals CKD, COPD, diabetes, CHF, CVD, Stroke/TIA Patients with one or more long term conditions Insulin, opiates, warfarin, NSAID, diuretics Patients on high risk medications Choose a cohort of patients that might be of higher risk Randomly generate list of 25 patients to work from

2. Systematic review of each record 20 mins per record No longer than 2 hrs STOP after 2 hrs OR when 5 harms identified It is NOT necessary to review all 25 records – look of the obvious learning opportunities 2. Systematic review of each record

Check each record for TRIGGERS over a 3 month calendar period If no triggers then Check each record for TRIGGERS over a 3 month calendar period

Check each record for TRIGGERS over a 3 month calendar period If no triggers then Check each record for TRIGGERS over a 3 month calendar period

Check each record for TRIGGERS if none then move to next record If no triggers then Check each record for TRIGGERS if none then move to next record

A trigger is NOT a patient safety incident

A trigger is NOT a patient safety incident It is a ‘prompt’ or a ‘flag’ that indicates that a patient safety incident has occurred MAY have occurred

A trigger is NOT a patient safety incident It is a ‘prompt’ or a ‘flag’ that indicates that a patient safety incident has occurred MAY have occurred -> undertake more focused examination of that patients records LOOKING for harm or “near misses”

Record each patient safety incident that you find on second page of Trigger Tool Data Collection Form

Patient safety incident

Patient safety incident

Severity Scale 1 2 3 4 Any incident with the potential to cause harm Mild harm: inconvenience, further follow-up or investigation to ensure no harm occurred. 3 Moderate harm: required intervention or duration for longer than a day 4 Prolonged, substantial or permanent harm, including hospitalization

Patient safety incident

Preventability Scale 1 Not preventable and originated external to this practice (secondary care or other provider) 2 Preventable and originated external to this practice OR not preventable and originating in this practice 3 Potentially preventable and originating in this practice 4 Preventable and originating in this practice

Patient safety incident

Incidental findings Clinical errors not resulting in harm in that patient Administration and system failures Inadequate record keeping Acts of omission E.g. Severe reactions to medications being incorrectly recorded only under ‘Note’ in Medtech

Case scenario 1 A 17 year old female patient presents with fever, no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. GP diagnoses bacterial tonsillitis, takes swab then recollects patient is allergic to penicillin and prescribes Erythromycin 800mg bd. Patient fully recovers.

Case scenario 1 A 17 year old female patient presents with fever, no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes.  GP diagnoses bacterial tonsillitis, takes swab then recollects patient is allergic to penicillin and prescribes Erythromycin 800mg bd. Patient fully recovers. During trigger tools process the GP realizes Penicillin Allergy not documented  and updates the PMS. 

Case scenario 1 Did Harm Occur – ? A 17 year old female patient presents with fever, no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes.  GP diagnoses bacterial tonsillitis, takes swab then recollects patient is allergic to penicillin and prescribes Erythromycin 800mg bd. Patient fully recovers. During trigger tools process the GP realizes Penicillin Allergy not documented  and updates the PMS.  Did Harm Occur – ?

Case scenario 1 Did Harm Occur – NO A 17 year old female patient presents with fever, no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes.  GP diagnoses bacterial tonsillitis, takes swab then recollects patient is allergic to penicillin and prescribes Erythromycin 800mg bd. Patient fully recovers. During trigger tools process the GP realizes Penicillin Allergy not documented  and updates the PMS.  Did Harm Occur – NO

Case scenario 1 Did Harm Occur – NO Potential for Harm - ? A 17 year old female patient presents with fever, no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes.  GP diagnoses bacterial tonsillitis, takes swab then recollects patient is allergic to penicillin and prescribes Erythromycin 800mg bd. Patient fully recovers. During trigger tools process the GP realizes Penicillin Allergy not documented  and updates the PMS.  Did Harm Occur – NO Potential for Harm - ?

Case scenario 1 Did Harm Occur – NO Potential for Harm - YES A 17 year old female patient presents with fever, no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes.  GP diagnoses bacterial tonsillitis, takes swab then recollects patient is allergic to penicillin and prescribes Erythromycin 800mg bd. Patient fully recovers. During trigger tools process the GP realizes Penicillin Allergy not documented  and updates the PMS.  Did Harm Occur – NO Potential for Harm - YES

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis.

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis.

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis. Did harm occur – ?

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis. Did harm occur –YES – thrush in response to penicillin

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis. Did harm occur –YES – thrush in response to penicillin Severity Scale – ?

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis. Did harm occur –YES – thrush in response to penicillin Severity Scale – 2 – mild harm/inconvenience

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis. Did harm occur –YES – thrush in response to penicillin Severity Scale – 2 – mild harm/inconvenience Preventability Scale – ?

Case scenario 2 A 17 year old female patient presents with fever ,no cough and a sore throat. The examination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes. No penicillin allergy. The GP takes a swab and starts Phenoxymethyl penicillin 1000mg bd. The patient recovers from tonsillitis but returns 7 days later with vaginal thrush. The swab confirmed strep tonsillitis. Did harm occur –YES – thrush in response to penicillin Severity Scale – 2 – mild harm/inconvenience Preventability Scale – 2 – not preventable and originated in this practice – OR if has had thrush before GP could have given empirical thrush treatment so potentially preventable i.e. 3

Case scenario 3 70 year old man with hypertension on a diuretic and an ACEI. Had been in with episode of gout and given NSAID. At bloods taken that week noted that eGFR had dropped from previous 45 to 25 ml/min

Case scenario 3 70 year old man with hypertension on a diuretic and an ACEI. Had been in with episode of gout and given NSAID. At bloods taken that week noted that eGFR had dropped from previous 45 to 25 ml/min Did harm occur ?

Case scenario 3 70 year old man with hypertension on a diuretic and an ACEI. Had been in with episode of gout and given NSAID. At bloods taken that week noted that eGFR had dropped from previous 45 to 25 ml/min Did harm occur –YES

Case scenario 3 70 year old man with hypertension on a diuretic and an ACEI. Had been in with episode of gout and given NSAID. At bloods taken that week noted that eGFR had dropped from previous 45 to 25 ml/min Did harm occur –YES Severity Scale ?

Case scenario 3 70 year old man with hypertension on a diuretic and an ACEI. Had been in with episode of gout and given NSAID. At bloods taken that week noted that eGFR had dropped from previous 45 to 25 ml/min Did harm occur –YES Severity Scale – 3 possibly 4?

Case scenario 3 70 year old man with hypertension on a diuretic and an ACEI. Had been in with episode of gout and given NSAID. At bloods taken that week noted that eGFR had dropped from previous 45 to 25 ml/min Did harm occur –YES Severity Scale – 3 possibly 4? Preventability Scale ?

Case scenario 3 70 year old man with hypertension on a diuretic and an ACEI. Had been in with episode of gout and given NSAID. At bloods taken that week noted that eGFR had dropped from previous 45 to 25 ml/min Did harm occur –YES Severity Scale – 3 possibly 4? Preventability Scale – 4

Learning examples of patient safety incidents identified Detecting a female patient with severe migraine attacks thought complicated by COC Warfarin and aspirin being co-prescribed inappropriately Temporary INR increase to >5 after prescription of oral antibiotic for suspected UTI Patient on methotrexate with drop in Hb found not had blood tests done for over 6/12

3.Reflection and further action Immediate action Reflection and opportunities for collective learning Individual practitioner learning needs 3.Reflection and further action

Acknowledge the detected harm (clinician and/or practice) – irrespective of whether errors had occurred If error involved it may be necessary to apologise to affected patients Intervene as appropriate to alleviate complications or prevent progression Consider audits to detect similar events Consider improvements to prevent recurrence of similar E.g. put in place recall for blood test, update allergies, call patient for review Immediate action

Individual and collective learning Share with practice team Discuss and identify improvement opportunities Prioritise Severity and likelihood or recurrence Origin and preventability Feasibility of solutions within practice E.g. GP updating on monitoring recommendations, practice education session on guidelines Individual and collective learning

Can be for patient safety incidents as well as incidental findings

Going back to your practice… How will you go about preparing and undertaking TT? What might be a useful cohort to identify patients at higher risk of patient safety incidents? How will you share your findings with the team and plan improvement actions?

How to get the most value from your Trigger Tool review Involve whole team Protected time Focus on SYSTEMS rather than errors Incorporate into ‘normal work’

Remember… Focus is on PATIENT SAFETY INCIDENTS - not ERROR would I want this to happen to me or my family? Specific period in the notes – 3 calendar months OBVIOUS problems If reasonable doubt about harm then leave it out You are unlikely to find something ‘dramatic’ – most records may not have trigger or patient safety incident No more than 20 minutes on each record

What to submit? Complete Trigger Tool Data Collection Form including Step 3 with Reflection, Action and Improvement part and submit whole form to SIP Don’t put NHI’s or patient details on form Suggest completing review by 28 Feb so time reflection, action and improvement with team prior to submission date of 29 March (Easter)

Questions? Comments?