Manaia Health PHO
Primary Care
Trigger Tool
Linda Holman
Quality Leader
Background
• Few studies on trigger tool use in primary care
• Primary care trigger tools have been used in
Scotland and England NHS
• Sensitivity and specificity of primary care trigger
tool in identifying harm not known
Method
• 37 triggers used initially
• 170 patients in one large general practice
identified
• 50% of cohort Māori
• Included children
• Record for one year reviewed looking for
presence of triggers and associated harm
• Record also reviewed for harm without any
trigger
• 2 review teams (GP + nurse/pharmacist)
WHO: National Coordinating Council
for Medication Error Reporting and
Prevention Index for Categorising Error
Category
Description
D
E
An error reached the patient and required monitoring or an intervention to confirm
it resulted in no harm
Temporary harm to the patient and required an intervention
F
Temporary harm to the patient and required hospitalisation of any length
G
Permanent patient harm
H
Intervention required to sustain life
I
Patient death
Findings
• 1034 triggers initially identified
• 40 030 days of follow-up
• 637 consultations
• Harm found in 63 of these triggers + 1
outside of the defined
triggers(corresponding to 45 individual
events)
• Harm categories:
E = 48, F = 11, G = 3, H = 0, I = 1
Rates of Harm
• Rate of harm: 0.07 (95% CI 0.05-0.09)
• Rate of harm per 100 patient years = 41 (95% CI
29-55)
• Rate of harm between Māori and non-Māori
no difference (adjusting for age and sex)
• Rate of harm if male 0.53 (95% CI 0.29-0.98)
adjusting for age and ethnicity
Triggers refined & reduced to 8
 Adverse reaction documented in PMS
 ≥ consultations with a GP in 1 week
 Cessation of medication
 Reduction in medication dose
 ≥6 medications prescribed
 Seen in ED/A+M within 2 weeks of seeing GP
 eGFR < 35
 Death
Efficacy of Refined Tool
• Odds ratio of harm occurring is refined trigger
tool used (adjusting for age, sex and ethnicity)
6.3 (95% CI 2.7-14.8)
• Sensitivity of refined trigger tool 0.88
• Specificity of refined trigger tool 0.48
Discussion
• Rates of harm comparable to published literature
in primary care
• Predominant cause of harm from medication
• Small number of harms that could be linked to
an actual error
• Value in pharmacist being involved
• Qualitative information gained during process
valuable
Trigger Definition
1
2
3
4
5
6
7
8
Adverse reaction there is an allergy/adverse drug reaction documented through the ‘alert’ system in
the PMS in the 12 month period.
>2 consults with a General Practitioner in the same general practice in a week. Multiple consults can
be the result of the patient being very unwell, needing review or the treatment not progressing as
predicted. Look for unintended events from other care/treatment that required consultation with
others afterwards.
Cessation of medications - Look for ‘stop’, ‘discontinue’ or ‘change’ of medication and the reason that
this was done. This may be due to factors such as drug interactions, development of side-effects, or
medication no longer indicated. It may also be related to a prescription error. Do not count
medication initiated as a trial unless there was a premature stop to the trial
>6 medications prescribed at the same time, at any time during the 12 month period, with all
medications having the potential to have a systemic response. Look for the concomitant use of six or
more medications, at anytime during the 12 month period. Look for evidence of drug interactions,
adverse drug events, development of side-effects, use of high risk medications eg oral anticoagulants,
insulin, oral hypoglycaemic, opiod analgesics. Be aware of topical medication with potential systemic
effects e.g. glaucoma drops
Reduction in medication dose - Look for change in the dose of a medication and the reason for the
decrease in dose. This may be due to factors such as change in medication regimen, development of
side effects, or drug interactions.
Attending Emergency Dept or After Hours provider within 2 weeks of having seen a General
Practitioner. Look for the reasons, could indicate for example an inadequate response to GP initiated
treatment, incorrect diagnosis, inability to access GP review or deterioration of the patients health.
eGFR (<35) Patients with results outside of range have a greater risk of experiencing an adverse event.
The lab value is only a trigger, so look for evidence of harm.
Death during the 12 month period.