Patient Safety and trigger tools

... what do we know?

 Lessons from Human Factors
Research

• Errors are common

• Errors are predictable
• The causes of errors are known

• Many errors are by-products of useful cognitive functions

• Many errors are caused by activities that rely on weak aspects of
cognition
• short-term memory
• attention span
What do we know?
Adverse events in general practice are wasteful
→ increased costs
→ reduced opportunities
→ reduced staff morale

Improving safety requires

good staff, good processes
responsive, learning organisations
generic measurement & improvement skills
good access, high quality care
 Human Error Taxonomy

Slip Attention
Failures

Unintended
Action

Lapse Memory
Failures
Errors /
Unsafe Acts Rule-Based
Mistakes
Mistake
Knowledge-Based
Mistakes
Intended
Action
Routine Violation

Violation Optimising Violation

Necessary Violation
Skill-based slips & lapses
• Often due to inattention and distraction

• Double capture slips

• Omission following interruption
• Reduced intentionality
• Perceptual confusion
• Interference problems
Rule-Based Errors
• Application of a good rule to the wrong situation

• Situation not well specified

• Cognitive overload
• Situation is an exception to a robust rule
Knowledge-Based Mistakes
• Inadequate understanding of situation

• Bounded rationality

• Difficulty in creating complete and accurate mental

representations of the problem space

• Heuristic strategies to cope with and reduce

complexity may result in mistakes
Summary
Human Error Typical Forms Common Prevention
Type Strategies
•Double capture •Minimise interruptions
Slip / Lapse •Omission •Forcing functions
•Interference •Colour-coding, highlighting
•Perceptual Confusion differences
•Checklists, memory aids
•Strong-but-wrong •Minimise / highlight
•Exception to rule exceptions
Rule-Based
Mistake •Cognitive overload •Provide feedback
•Manage workload
•Confirmation bias
Knowledge- •Out of sight, out of mind •Decision support
Based Mistake •Encystment •Team work & CRM training
•Vagabonding
 Human error

The search for and understanding of errors has not made

patient care much safer

Error is normal
... what are you going to do about it?
Who always drives at 30mph?
Systemic Migration to Boundaries
INDIVIDUAL BENEFITS

Life Pressures
Driving
50 mph – the
VERY UNSAFE SPACE Driving 35
‘illegal-illegal’ The speed
mph- the
space (for limit is
‘Illegal- Perceived
almost all of 30 mph-
normal’ vulnerability
us!) the ‘legal’
space
space

Belief
Systems

ACCIDENT
PERFORMANCE
Prescribing a PPI with NSAID

• What is your policy for prescribing a PPI with a NSAI

for patients over 60 years old?

• Do you observe it every time?

• When do you (choose) to violate?

• How far is it safe to migrate?

Systemic Migration to Boundaries
INDIVIDUAL BENEFITS

Life Pressures
I’ve never had
a patient PPI for
VERY UNSAFE SPACE patients >60
harmed by Every
NSAID so don’t when I
patient >60
use a PPI remember or Perceived
on a NSAID
those with vulnerability
gets a PPI
history of GI
disease

Belief
Systems

ACCIDENT
PERFORMANCE
 Performance must be understood
in a broad context

System production
Commercial stress
Coping and resiliency
Individual advantages
Productivity

• Migrations/violations are often seen first as

benefits with immediate payback
• saving time
• increasing productivity

• Tension between following protocol and

productivity
 Results of Migration

• Migrations lead to a large range of illegal practices

• Over time these become “normal” for the system -

stabilized

• All stakeholders in the system migrate and violate

• Migrations differ for individuals and roles
• E.g. senior management or actors in the field
What not to do
Don’t conclude “Policies must be stricter, clearer, and implemented”
• Individuals make cost/benefit decisions on compliance. Too stringent
implementation can lead to violation/migration.

Don’t resort to exhortation “Work Harder/Better”

• Don’t just send a memo about the old, written rule
• Take a systems view
Managing Migrations
INDIVIDUAL BENEFITS Policy, Protocols, 1. Individuel or collective
‘Real Life’
2. Acknowledge Regulation eexperience of incidents, share
individual stories
variation in risk Agree stop rule to migration
acceptance. Life Pressures
System response
‘Illegal- BTCUs
‘Illegal-Illegal’required
VERY UNSAFE SPACE 3. Space
Forbidden Normal’
space, except Always/
under extreme
Expected safe
Never/ Always/Always space of
pressure/ Technology
Sometimes
conditions Sometimes action as
4. Agreed defined by
forbidden professional
space for all standards
staff
Never/ Suppress triggering
AddNever
defences Accept and adapt Market
conditions
and Just protocols and Demand
Human Factors
Blame defences
Reliability
ACCIDENT
PERFORMANCE
Work harder. Be more vigilant. Follow the protocol and other useless interventions!
Human error

“We can’t change the human condition,

but we can change the conditions under
which humans work”

James Reason
A systems approach

• make it easier to do the right thing

• make it harder to do the wrong thing

• redesign processes, to allow you to spot & stop errors

reaching the patient
 A systems approach

Factors Influences
Patient Condition (complexity & seriousness)
Language and communication
Personality and social factors
Task and Technology Task design and clarity
Availability and use of
Availability and accuracy
Decision-making aids

Individual (staff) Knowledge and skills

Competence
Physical and mental health
Team Factors Verbal communication
Written communication
Supervision and seeking help
Team structure (congruence, consistency, leadership)
 A systems approach

Factors Influences
Work Environmental Staffing levels and skills mix
Workload and shift patterns
Design. availability and maintenance of equipment
Administrative and managerial support
Environment

Organisanonal & Financial resources & constraints

Management Organisational structure
Policy, standards and goals
Safety culture and priorities

Institutional Context Economic and regulatory context

National health service executive
Links with external organisations
 A systems approach

Conduct review of organization

• Are processes simple and standardized?
• Are failure identification and mitigation systems in place? (more on this later)

Conduct a task analysis

• How many interruptions are there during the work shift?
• How complex are the tasks or instructions?

Conduct human factors audits

• Noise levels; distractions; design of workspace; label format; work hours and reviews

Train staff in human factors awareness

Adapted from REASON, 2005
Organisation
Environment
Workspace
Factors within
Task
The ‘system’ the healthcare
Equipment
system that
People could potentially
lead to harm

Staff Staff act

as harm
absorbers
Patients
 ‘Three bucket’ model for
assessing risky situations
(Reason, 2004)

3
2
1

SELF CONTEXT TASK

The fuller your buckets, the more likely something will
go wrong, but your buckets are never empty.
Assessing the risk

9 • Serious risk: don’t go there / change something

7
• Moderate to serious: be very wary
5

3 • Routine to moderate: proceed with caution

Self Bucket

Level of knowledge training

Level of skill competence and

experience
involuntary automaticity,
Level of experience
under/over confidence

Current capacity to do fatigue, time of day,

the task distractions, feelings
Context Bucket

Equipment and devices availability, familiarity

Physical environment lighting, noise,

temperature
Workspace working environment,
writing space, layout

Team and support leadership, stability and

familiarity, trust
Organisation and safety culture, goals,
management targets and workload
Task Bucket

Task calculations, multiple

complexity cognitive tasks
Novel task unfamiliar or rare events
Process task overlap, multi-tasking
 ‘Three bucket’ model for
assessing risky situations
(Reason, 2004)

3
2
1

SELF CONTEXT TASK

The fuller your buckets, the more likely something will
go wrong, but your buckets are never empty.
Understanding & measuring
patient safety
Take a broader view
Use information appropriately
Prioritise deliberately
Be more proactive
Use casenote review
So many questions!

• How many of our patients are

harmed?
• Which areas need most attention ?
• What’s causing adverse events ?
• What changes could we implement?
• Are the changes an improvement ?
 Trigger Definition
1 Adverse reaction there is an allergy/adverse drug reaction documented through the ‘alert’ system in
the PMS in the 12 month period.
2 >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.

3 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

4 >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

5 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
6 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.

7 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.
8 Death during the 12 month period.
PRELIMINARY CANADIAN PEDIATRIC TRIGGERS
  CARE MODULE
C1
C2
Transfusion/ use of blood products
Any code or arrest
94 47 triggers
C3 Dialysis (New Onset)
C5 Diagnostic Imaging for Embolus/thrombus with/without confirmation
C7 Patient fall
C8 Decubiti / Skin Breakdown
C9 Readmission within 30 days
C10 Restraint
  use MEDICATION MODULE
C11 InfectionM6
of anyVitamin
kind K (excluding newborns)
C12 In hospital stroke
C13 Transfer M7 Benadryl
to higher level of(Diphenhydramine)
care - for symptoms of allergic reaction

C14 Procedure complication

M8 Romazicon (Flumazenil)
C16 Rash
M9 Narcan (Naloxone)
C17 Hypotension
C18 CatheterM10 Anti-emetic Use (for treatment of symptoms)
infiltration/burn
C19 Wrong Maternal Breast Milk
M11 Over sedation / hypotension
C20 Incorrect Central Venous Catheter (CVC) placement (radiographic)
C21 Complication
M12 related
Abrupttomedication
Central Venous
stop Catheter (CVC)
C22 Necrotizing Enterocolitis (NEC)
C23 Seizures Antidiarrheals - Diphenoxylate (Lomotil), Loperamide (Imodium),
M14
Kaopectate, Pepto-Bismol
 Primary Care Trigger Tool
We need a metric

•Focus on actual patient harm

•How many patients had an adverse

event last year?

•What are the common areas of harm?

•Have our changes succeeded in

reducing the incidence of harm ?
 Primary Care Trigger Tool
We need casenote review

Staff reporting Casenote review

• subjective • objective
• focus on error • focus on outcomes
• focus on memorable • focus on common events
events (rare)
• large numbers
• v small numbers • reliable over time
• variable over time
We need trigger tools
Problems of casenote review
• lengthy, experienced clinician
• wasteful (reviews with no adverse events)

Trigger Tools – a solution

• filtered & targetted → quicker, cheaper, less wasteful

1. Filter out patients with low likelihood of adverse event

2. Target clinical review where harm is suspected
Step-by-step A. Sample
• List of all patients > 75 years

• Place in random order

• Each month, select 25-100 for PCTT review

• Review the past 3 months

Step-by-step B. Review
Sample
50 patients

1. Search for triggers [clerical] NO

• unambiguous proxy indicators of harm risk 0 events
30 patients

YES 20 patients

2. Search for adverse events [clinical] NO

• iatrogenic harm events 0 events
10 patients
YES 10 patients
12 events

Event rate = 12 / 50 = 0.24

 Step-by-step C. Analyse
Adverse event rate
Monthly sample of patients provides mean adverse event rate for practice
0.4

0.35

0.3

0.25

Change 1
0.2

0.15

0.1

0.05

0
Step-by-step C. Analyse
Primary Care Trigger Tool

 Identify common harms

 Measure improvement over time

× Not valid for benchmarking

Primary Care Trigger Tool
Medication Patient transfer
Repeat medication discontinued Readmission to hospital within 2 weeks of
Prescribing of opioid analgesia discharge

Prescribing oral NSAID/COX2 Laboratory

Prescribing warfarin Na+ <130 or >150 mmol/l

Prescribing insulin K+ <3.5 or >5.5 mmol/l

Prescribing methotrexate
Prescribing amiodarone Haemoglobin <9g/dl
MRSA positive
General Care
C.diff positive
Seen > once in 2 days
Positive wound/skin swab
Fall if age > 75
eGFR <= 20
Fracture if age > 75
End of life
Pressure sore or ulcer
Death
Urinary catheter in situ
Key diagnosis
VTE
New diagnosis of CVA/TIA
Proven DVT or PE
New diagnosis of acute confusional state
eg – Warfarin & bleeding
.. Trigger

• INR > 5 is a trigger on the PCTT

• Many patients with an INR > 5

come to no harm

• This is not an adverse event

(even if results from error)
eg – Warfarin & bleeding
.. Adverse event

• Retinal bleed caused by Warfarin 

• Patient has come to harm

• This is an adverse event (whether

result of error or not)
Primary Care Trigger Tool

www.institute.nhs.uk/safercare/TTP