Appendix 1: The trigger tool process What is the aim of the review? A practice aims to improve the safety of patients prescribed anticoagulants. team agrees to record the number of triggers and patient safety incidents for the last three months. Sampling: size and method? and Twenty five records w ill be randomly selected from the Triggers: number register of patients that meet the inclusion criteria. prepare and type? Seven triggers are chosen (Box 1). trigger ‘Additional >5 is added. ‘INR What data should be collected? Individual and Team The practice nurse will conduct the preliminary responsibilities? review . Detected PSIs will be verified by a named GP. An administrator will code the data. Review records Can triggers be detected? No Yes. For each detected trigger, consider: Review the next record Did a PSI occur? No. Continue to Yes. Summarize the incident and next trigger or judge three characteristics: record Severity? Preventability? PSI and apologize to patients, •Acknowledge Patient and necessary medical audits to detect similar events •Consider records improvements to prevent recurrence of •Consider similar incidents. personal learning for improvement, •Identify appraisal and governance Reflection, findings with the team •Share and reflect on findings •Discuss further action improvement efforts according to •Prioritize Practice team detected PSIs secondary care interface • Consider appropriate feedback incident reporting through local and •Consider national systems a joint SEA •Consider
Appendix 1: The trigger tool process What is the aim of the review? A practice aims to improve the safety of patients prescribed anticoagulants. and prepare What data should be collected? Sampling: size and method? Triggers: number and type? team agrees to record the number of triggers and patient safety incidents for the last three months. Twenty five records w ill be randomly selected from the register of patients that meet the inclusion criteria. Seven triggers are chosen (Box 1). ‘Additional trigger ‘INR >5 is added. Individual and Team responsibilities? The practice nurse will conduct the preliminary review . Detected PSIs will be verified by a named GP. An administrator will code the data. Review records Can triggers be detected? No Review the next record Yes. For each detected trigger, consider: Did a PSI occur? Yes. Summarize the incident and judge three characteristics: No. Continue to next trigger or record Severity? Preventability? Patient and medical records •Acknowledge PSI and apologize to patients, necessary •Consider audits to detect similar events •Consider improvements to prevent recurrence of similar incidents. Reflection, further action Practice team •Identify personal learning for improvement, appraisal and governance •Share findings with the team •Discuss and reflect on findings •Prioritize improvement efforts according to detected PSIs care interface • Consider appropriate feedback •Consider incident reporting through local and national systems •Consider a joint SEA secondary
the-primary-care-trigger-tool-gudance-nh-dmcn-nov-2015.docx