Quality Education for a Healthier Scotland Medicine Safety & Improvement in General Medical Practice Trigger Review of Clinical Records Paul Bowie Associate Adviser Postgraduate GP Education NHS Education for Scotland 2 Central Quay, Glasgow

Quality Education for a Healthier Scotland Medicine Content and Purpose of Session Content Brief presentation: Overview of Trigger Review concept Go over Trigger Review Documentation Q&A Exercise: trigger review of simulated record Group reflection on what was found and the “answers” Final questions Purpose To describe the Trigger Review concept and provide basic training in applying the Method Learning outcomes You understand the principle of the Trigger Review Method You are reasonably confident in your ability to try it out back in practice

Quality Education for a Healthier Scotland Medicine Brief Summary – What is Trigger Review? Reviewing your clinical records is the oldest form of audit! Looking for evidence of (undetected) safety incidents/latent risks Help you direct safety-related learning and improvement Quick and Structured versus Slow and Open Clinical triggers help you to navigate your records quickly Links with SEA and Quality Improvement Evidence for QOF, Appraisal and GPST etc. Random sample of 25 patients – high risk groups (e.g. >75 years, multiple morbidity/poly pharmacy) Review the last 12-week period only (x2 6mths apart for QOF) Takes between 90 minutes to 3-hours Tested with large groups of GPs, Practice Nurses and GP Trainees

Quality Education for a Healthier Scotland Medicine “Triggers” in Clinical Records ‘‘Triggers’’ are defined as easily identifiable flags, occurrences or prompts in patient records that alert reviewers to actual or potential safety incidents (undetected) Sections in GP RecordsTriggers Clinical encounters (documented consultations) ≥3 consultations in 7 consecutive days Medication-related (acute and chronic prescribing) Repeat medication item stopped Clinical read codes High, medium, low, allergies New ‘high’ priority or allergy read code Correspondence Section Secondary care, other providers OOH / A&E attendance / Hospital admission Investigations Requests and results eGFR reduce 5.0

Quality Education for a Healthier Scotland Medicine Detecting Patient Safety Incidents in GP Clinical Records: Proof of Principle Two GPs reviewed 500 randomly selected electronic patient records (100 x 5 Scottish GP practices): 12-month period. Clinical triggers developed and tested help to pinpoint safety incidents 9.5% of records contained evidence of unintentional harm to patients 60+% were judged to be preventable Most cases low to moderate severity, all severe cases originated in secondary care Scope for safety-related learning and improvement (in the same way as SEA or Audit) De Wet & Bowie, Postgraduate Medical Journal, 2009

Quality Education for a Healthier Scotland Medicine Safety Incidents in GP – Feedback Sources e.g.

Quality Education for a Healthier Scotland Medicine What is a trigger review of clinical records? A ‘Trigger’ is a pre-defined prompt or sign in the record that MAY indicate that a patient safety incident has occurred – roughly defined as any incident, however minor, where a patient was harmed, may have been (i.e. a near miss), or could be in future (i.e. a latent risk) Detected Trigger(s): a signal for the reviewer to undertake a more in-depth review of the record to determine if evidence of a safety incident exists. For example, an INR>5.0 (a trigger) was detected by a clinical reviewer - further review of the record found evidence of the patient having suffered a bleed and being admitted to a local hospital (a patient safety incident). If a safety incident is uncovered, the reviewer makes a professional judgement on whether it was avoidable or not, how severe it was and if it originated in primary care or elsewhere. Helps to pinpoint incidents where learning and improvement are a greater priority - may be necessary if multiple incidents are detected.

Quality Education for a Healthier Scotland Medicine Why do it? Most evidence about safety incidents is detected in the clinical record. Feedback from Pilot Project teams and others suggests: - The triggers used are valid i.e. they can be detected and may be indicative of safety incidents if these actually occurred. - The process is acceptable i.e. GPs and Nurse who tried it report that it is of value professionally, educationally and to making patient care safer. - The process is feasible i.e. GPs and Nurses were generally able to apply the method and learn from it. Pragmatic issues around time taken and the opportunity cost associated with the method require further study. -The process can lead to improvements. GPs and Nurse reported a range of actions and improvements undertaken as a result of participation. -Note: - most detected incidents are of low severity or are ‘near misses’ – but offer valuable opportunities for learning and minimising future risks. -Provides opportunities to take PRE-EMPTIVE action before incidents occur or pinpoint learning needs where patient safety was avoidably compromised.

Quality Education for a Healthier Scotland Medicine Examples of Potential High Risk Patient Sub- Populations to Review 1. Specific, Shared Patient Characteristics 2. Chronic Disease Areas3. High risk Medications Nursing Home patientsCOPDInsulin >75yearsStroke/TIAMorphine Last 25 attending out-of-hoursCVDWarfarin Housebound patientsDiabetesNSAIDs Last 25 hospital admissionsHeart failureDiuretics(x2) Last 25 hospital referralsCKD>5 repeat Medication items 4. Combinations of Groups 1 to 3 e.g. patients over 75 years with CVD, taking >5 repeat medication items

Quality Education for a Healthier Scotland Medicine PS1.3 Practice Guidance Patients on DMARD therapy Patients with diagnosis of Left Ventricular Systolic Dysfunction Patients on Warfarin therapy Patients with a higher SPARRA score e.g over 40 Recent admissions with COPD Care home residents Patients on chronic District nursing caseload Patients aged 75 years on 6 or more medications

Quality Education for a Healthier Scotland Medicine How to Undertake a Trigger Review When examining a record, the reviewer looks to answer the following 5 questions: 1. Can triggers be detected? If yes, the reviewer examines the relevant section of the record in more detail to determine if the patient came to any harm. If no, move onto the next record - average review time is 2 to 3 minutes 2. Did harm occur? If yes, move onto the next question on the proforma sheet. If none is detected, move onto the next record. After 20 minutes if unable to decide if harm occurred you ignore the record and move on. 3. What was the severity of harm detected? The reviewer should rate the severity of every incidence detected. 4. Was the detected harm incident preventable? The reviewer should determine whether the detected incident was preventable - based on a combination of evidence found and professional judgement. 5. Where did the harm incident originate? The circumstances leading to the incident may have originated in primary or secondary care, or a combination of both.

Quality Education for a Healthier Scotland Medicine Examples of improvements made during trigger review: 1.Nephrotoxic medication discontinued. 2.Drug dosage (warfarin) adjusted. 3.Referral letter to secondary care done (x3). 4.Allergy or adverse reaction code updates. 5.Medication reviews done. 6.Medication adjustments made. 7.Initiated follow up appointment for patients requiring review. 8.Cardiotoxic drug discontinued. 9.Updated notes with investigation. 10. Follow up blood test arranged.

Quality Education for a Healthier Scotland Medicine What do we find with the Trigger Tool? 1.An adverse drug reaction to codeine is detected, but has not been entered as a clinical ‘read code’. The clinician enters the appropriate read code to help prevent prescription of this item in the future. 2.A harm incident was detected where a patient had to be hospitalized after falling and sustaining a large laceration. The clinician identifies drug-induced postural hypotension as a likely contributing factor. She recalls a telephone discussion with a relative who expressed concern about the patient’s ability to manage at home which had not been documented at the time. She takes a few minutes to retrospectively update the record. 3.The clinician finds a positive trigger - ‘repeat medication item discontinued’ - but there is no reason documented for this change during the consultation. She discusses her finding with her colleague who made the entry. He clarifies the record by retrospectively adding his rationale for stopping the medication.

Quality Education for a Healthier Scotland Medicine 4.While scanning the medical record for the trigger ‘Hb<10’, a clinician discovers that an elderly patient on Warfarin has not had her haemoglobin checked for at least five years. She discusses this with the practice nurse who adds this test during the patient’s next phlebotomy appointment. 5.Detecting information in a record which is strongly indicative of preventable harm (but no harm incident occurred), may act as a red flag that points to other patients in the group under review facing increased clinical risk. For example, detecting a patient being inappropriately co-prescribed Warfarin and Aspirin, led to a wider audit which uncovered two other similar cases. The practice took immediate corrective action for the patients concerned and to help prevent future harm from this specific safety threat. 6.A harm incident was detected where a GP inappropriately prescribed a high dosage of an antipsychotic drug causing increasing confusion, falls and injury to a patient in a nursing home. A learning need to improve knowledge of patients with dementia and problematic behavioural symptoms is identified. GP attends a two hour evening workshop presented by a local psychiatrist dealing with this subject. What do we find with the Trigger Tool?

Quality Education for a Healthier Scotland Medicine Learning from Undertaking Trigger Review PERSONAL/PROFESSIONAL Revise medication interaction Importance of highlighting coding as a safety issue. Need to give more attention to OOH summary sheet. Review SIGN and NICE CHD Guidelines. Inaccurate repeat medications reviews and need to action more thorough reviews Need to update diabetic guidelines on therapeutics and management Need to code adverse reaction. Need to update knowledge on management and therapeutics of heart failure. Need for new knowledge on gout management How to liaise with social services re respite. Factors involved (medical & social) in Warfarin prescribing. How different Quality improvement (QI) techniques can be used. Recognition of the ‘cascade of error’ and analysis and need for route cause analysis

Quality Education for a Healthier Scotland Medicine PRACTICE LEVEL Need system for dealing with OOH mail Need system for better medication reviews/monitoring. Need for adverse event coding. Need to develop protocol for falls prevention Need for developing more continuity in patient care. Address appointment availability. Examine how hospital discharge prescriptions are actioned. How to highlight medication errors to allow action. To improve communication within primary care team. How to carry out QI techniques. Learning from Undertaking Trigger Review

Quality Education for a Healthier Scotland Medicine Trigger Review - Truths and Myths What it Can DoWhat it Cannot Do Help find undetected patient safety incidents Detect all incidents Detect more safety-related incidents than any other method Tell you the why, where, what and what now It can be fitted into a single sessionImprove care by itself Potentially measure harm at regional and national levels Practice level measurement or ‘benchmarking’.

Quality Education for a Healthier Scotland Medicine Remember... The focus is patient safety incidents and not error. Ask yourself: ‘Would I have wanted this to happen to me or my family?’ Only review the specific period in the record (3-months). Choose full calendar months to facilitate the review. The maximum time spent on reviewing any record should be twenty minutes. The objective is to detect ‘obvious’ problems, rather than every single episode. Most records do not contain triggers or evidence of incidents – these only take a few minutes to review If there is reasonable doubt whether a safety incident occurred, the incident should not be recorded. Use the team to assist in searching (admin) for and reviewing (nurse) records

Quality Education for a Healthier Scotland Medicine

Quality Education for a Healthier Scotland Medicine