The Detecting and Reducing Patient Safety Incidents in Primary Care. Using Structured Case Review Trigger Tool

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1 The Detecting and Reducing Patient Safety Incidents in Primary Care Using Structured Case Review Trigger Tool Dr Neil Houston, Clinical Lead for Patient Safety in Primary Care, NHS Scotland GP / Patient Safety Advisor

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3 Patient Safety Incident" Any unintended or expected incident which could have or did lead to harm for one or more patients receiving NHS Care!

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8 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"!

9 Aim? Patient and medical records Data? Practitioner level Sampling: size and method? Individual and Team responsibilities? Triggers: number and type? Practice team Primary-secondary care interface 1. Plan and prepare 2. Review records 3. Reflection, further action Can triggers be detected? No Yes. For each detected trigger, consider: Review the next record Did harm occur? Yes. Summarize the harm incident and judge three characteristics: No. Continue to next trigger or record Severity? Origin? Preventability?

10 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.!

11 Aim? Patient and medical records Data? Practitioner level Sampling: size and method? Individual and Team responsibilities? Triggers: number and type? Practice team Primary-secondary care interface 1. Plan and prepare 2. Review records 3. Reflection, further action Can triggers be detected? No Yes. For each detected trigger, consider: Review the next record Did harm occur? Yes. Summarize the harm incident and judge three characteristics: No. Continue to next trigger or record Severity? Origin? Preventability?

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13 Choose the patient group with the biggest chance of finding something"

14 Medical records and triggers" Sections in GP records" Clinical encounters " (documented consultations)! Medication-related " (acute and chronic prescribing)! Clinical read codes " High, medium, low, allergies! Correspondence Section" Secondary care, other providers! Investigations! Requests and results! Triggers" 3 consultations in 7 consecutive days! Repeat medication item stopped! New high priority or allergy read code! OOH / A&E attendance / Hospital admission!! egfr reduce <5!!

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16 What about NZ triggers"

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18 Key Point" A trigger is not the same as harm or a patient safety incident!

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23 Gordons Video Clip V Seemed a bit intimidating when we first had it presented to a large group much easier to use in practice it s a remarkably effective tool for reflective analysis on patient safety and other clinical issues has created a lot of interest from other doctors in the practice as a tool for professional development and for appraisals Doctor Gordon Cameron GP Edinburgh

24 Experience Generally received positively Quick Finding Harm Focus for Improvement Cultural change Need training and support Not for measurement

25 A patient re-consulted with an allergic reaction to a prescribed antibiotic. Found to have had similar incident years before not coded!

26 Elderly housebound patient admitted with a fracture femur after falls.! Multiple BP medications not reviewed two years!

27 Harm! Adverse drug reactions - ADRs Co prescribing Unrecorded ADR s Missing read codes Lack of follow-up Not Monitoring drugs

28 Examples of improvements made DURING trigger review: "! Nephrotoxic medication discontinued.!! Drug dosage (warfarin) adjusted.!! Referral letter to secondary care done (x3).!! Allergy or adverse reaction code updates...!! Cardiotoxic drug discontinued.!!!

29 Learning.." 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.!

30 Remember..." The focus is patient safety incidents and not error.! Only review the specific period in the record (three months).! Choose full calendar months to facilitate the review.! The maximum spend on reviewing any record should be twenty minutes. The objective is to detect obvious problems.! If there is reasonable doubt whether a PSI occurred, don t record it.! You are unlikely to find something dramatic " The majority of records may not have triggers or PSI"

31 How to get value from your trigger Focus on systems?! Provide protected time! reviews" Empower your nursing and admin colleagues! Involve your team! Any volunteers? The reflective type or IT boffin?! Incorporate it into normal work (SEA, audit, appraisal)!

32 It is not for everyone!"

33 Quantifying harm for the sake of measurement activity is non-productive!!!!!!!roger Resar, 2003, QSHC.! The priority is to turn measurement for improvement into tangible change in practice!!!!!!scott, I; Phelps, G Int. Med J.!

34 Questions?"

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