1. Trigger Tool
Dr Lisa Eskildsen
Nov 2017

2. 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

3. 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

4. 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)

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

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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. A trigger is NOT a patient safety incident

21. 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

22. 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”

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

24. Patient safety incident

25. Patient safety incident

26. 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

27. Patient safety incident

28. 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

29. Patient safety incident

30. 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

31. 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.

32. 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. 

33. 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 – ?

34. 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

35. 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 - ?

36. 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

37. 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.

38. 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.

39. 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 – ?

40. 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

41. 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 – ?

42. 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

43. 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 – ?

44. 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

45. 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

46. 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 ?

47. 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

48. 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 ?

49. 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?

50. 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 ?

51. 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

52. 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

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

54. 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

55. 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

56. Can be for patient safety incidents as well as incidental findings

58. 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?

59. 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’

60. 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

61. 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)

62. Questions? Comments?