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Trigger Review Method

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This page contains information and tools on person-centred approach to quality improvement and building a safety and improvement culture in primary care, developed or supported by members of the NES Patient Safety Multi-disciplinary Group. it includes information on the 'Always event' concept and Trigger Tool for quickly screening patient records.

Trigger Review Method

This poster describes how to apply the trigger tool process as a feasible part of routine practice and promotes the idea that the trigger method will enable the primary care team to refocus their measurement, learning and improvement efforts on one of the most serious issues facing the NHS - minimising the risk to patients of unintentional but avoidable harm.

What is the Trigger Tool method?

The Trigger Review Method (also known as a trigger tool) allows primary care clinicians to review small samples of the electronic medical records of high risk patient groups (e.g. patients over 75 with multi-morbidity) for previously undetected patient safety incidents, hazards and near misses in a structured, focused, rapid and active manner.

Why would you choose this?

This QI method aims to rapidly identify previously undetected patient safety incidents in a particular patient group. This allows these to be rectified and the design of changes to prevent recurrence

What is it useful for?

This method allows practices to identify avoidable harm that may previously not have been recognised. It involves a quick, focused review of a sample of notes so gives an idea of how practices are performing across a whole population.

What is it not useful for?

• This is not a useful method to review a specific incident, another method that allows reflection and change on specific incidents would be better.

• It identifies potential harm and can result in changes being agreed and implemented but often other QI methods can be used to make changes and improve quality (e.g. Criterion Based Audit or the Model for Improvement).

Who can do/lead it?

This method involves reviewing electronic case notes and can be done by any appropriately trained clinician. Administrative staff can support this by conducting searches and even identifying ‘triggers’

How do you do it?

Planning and preparation The team should meet and decide on the aim of the review which will inform how records are sampled and what triggers are used. Triggers are easily identifiable flags, occurrences or prompts in patient records that alert reviewers to potential adverse events that were previously undetected.

Systematic Review of the Records Clinical notes are reviewed and the following information collected. Is a trigger present? If so has harm occurred and what is the severity? Finally, was the detectable harm preventable and where did it originate? There are standard proformas available that can make this process easier.

Reflection and Further Action Depending on what incidents are picked up immediate action may be required (e.g. medication change). The results should be shared and discussed with the whole practice team so that individual and practice learning needs can be identified. Evaluating and sustaining change is important, using the same method and repeating the process regularly is necessary to ensure this.

Who else does it involve?

The whole practice team should be involved in sharing of results to allow for individual and collective learning needs to be identified

Top Tips

• All normal Top Tips (listed for page four) for QI apply here.

Further Info

An example of the proforma that practices can use for their reviews is found here

An example of the findings of a trigger tool and how that information was used is described below.

Population selected: Patients ≥75 years and on cardio vascular disease (CVD) register 25 sets of notes reviewed and 28 triggers found from 12 patients.

The following patient safety incidents were found:

1. Patient presented with lethargy not known to be diabetic. HbA1c taken and was raised (HbA1c = 7.1). No action taken.

2. Prescribed ramipril on recommendation of hospital. Patient had a vasovagal episode resulting in overnight admission. Ramipril stopped.

3.  Dihydrocodeine requested and prescribed too frequently.

4. On NSAID for gout but had known Chronic Kidney Disease (CKD) 3. eGFR last year was 44. Dropped to 34 when on NSAID for gout.

Practice Action

1. Discussion and agreement on protocol for diagnosing diabetes and handling of HbA1c results.

2. Change to labelling used on bloods from the diabetes clinic to ensure these are easily identified.

3. Alteration of EMIS template to show issuing frequency on the right-hand side of the prescription.

4.  Training of admin staff to highlight when generating repeat prescription.

5.  Educational session on management options for gout.

6. The case where the patient was admitted after prescribing ramipril was reviewed. This was not thought to be preventable as management was considered appropriate, for example, bloods and blood pressure had been recently checked, the patient warned about the side effects and risk of intercurrent illnesses such as diarrhoea and vomiting illnesses

Trigger Review Method guidance and case studies: