Safety

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Safety Improvement in General Medical
PracticeTrigger Review of Clinical Records

• Paul Bowie
• Associate Adviser
• Postgraduate GP Education
• NHS Education for Scotland
• 2 Central Quay, Glasgow
• paul.bowie_at_nes.scot.nhs.uk

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Content and Purpose of Session

• Content
• Brief presentation Overview of Trigger Review
  concept
• Go over Trigger Review Documentation
• QA
• 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

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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. gt75 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

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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 Records Triggers
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 / AE attendance / Hospital admission 
Investigations Requests and results eGFR reduce lt5, Hb lt 10.0, INR gt 5.0
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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

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Safety Incidents in GP Feedback Sources e.g.
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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 INRgt5.0 (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.

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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.

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Examples of Potential High Risk Patient
Sub-Populations to Review
1. Specific, Shared Patient Characteristics 2. Chronic Disease Areas 3. High risk Medications
Nursing Home patients COPD Insulin
gt75years Stroke/TIA Morphine
Last 25 attending out-of-hours CVD Warfarin
Housebound patients Diabetes NSAIDs
Last 25 hospital admissions Heart failure Diuretics(x2)
Last 25 hospital referrals CKD gt5 repeat Medication items
4. Combinations of Groups 1 to 3 e.g. patients over 75 years with CVD, taking gt5 repeat medication items 4. Combinations of Groups 1 to 3 e.g. patients over 75 years with CVD, taking gt5 repeat medication items 4. Combinations of Groups 1 to 3 e.g. patients over 75 years with CVD, taking gt5 repeat medication items
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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

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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.

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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.
• Medication reviews done.
• 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.

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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 patients 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.

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What do we find with the Trigger Tool?

1. While scanning the medical record for the trigger
   Hblt10, 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 patients next phlebotomy appointment.
2. 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.
3. 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.

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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

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Learning from Undertaking Trigger Review

• 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.

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Trigger Review - Truths and Myths
What it Can Do What 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 session Improve care by itself
Potentially measure harm at regional and national levels Practice level measurement or benchmarking.
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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

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Simulated Exercise