Can using trigger tools engage the clinical team and raise the profile of safety in practice

Talk Code: 
Tom Margham
Sally Hull
Author institutions: 
Tom Margham: Jubilee Street Practice, Sally Hull: Centre for Primary Care and Public Health Queen Mary University of London


Working in general practice can feel like you're running on a hamster wheel that is spinning faster and faster. The way we work, high risk and high volume, and the pressures we are under set us up to make mistakes. For many clinicians the main reflective work undertaken around safety is significant event analysis. These tend to be sentinel events such as a delayed diagnosis that, whilst important, are low frequency and tend to hold the focus of clinical teams to the detriment of areas of high risk that remain in our peripheral fields of vision. The challenge for busy GPs is knowing where to look to understand more about how safe their practice is. How do you find the safety needle in a haystack of work?


Trigger tools have been in use for around 10 years. Most recently they have been included in the RCGP patient safety toolkit. However, the existing design of trigger tools has drawbacks that are likely to limit uptake by busy GPs - they are reliant on random case reviews which are labour intensive and generate a lot of ‘noise’ and not enough ‘signal’ when it comes to flagging-up patient safety incidents. - We developed, tested and refined six Emis-based searches to identify patients at higher risk of iatrogenic harm- Searches covered a range of clinical activity: prescribing, critical diagnoses and results handling- Searches were complemented by smart worksheets which guide clinicians through a reflective process in a way that is straightforward and can be completed in minutes- Completed worksheets can be exported in one click, with patient identifiers removed, to your appraisal folder. So it can be used as evidence of reflective practice for revalidation


- We undertook over 100 casenote reviews - Trigger tool searches identified actions that need to be taken to remedy potential patient safety problems in 45-90% of cases reviewed- It’s small ‘sins of omission’ that have the potential to add up to harm patients. Checks that aren’t undertaken, abnormal results not actioned or codes that aren’t entered in the record are the kinds of errors picked up by the trigger tool searches. These errors can so often sit under the radar but can have significant consequences for patients.


- We found that by making the right thing easy to do, it is possible to engage busy GPs in reflective work around patient safety- GPs value the opportunity to look on areas of their clinical work and found the trigger tool searches helped to focus their activity in a meaningful way- The ‘plug and play’ design of the trigger tool searches and worksheets mean that they can be easily used by other practices.

Submitted by: 
Tom Margham
Funding acknowledgement: 
The trigger tool project was made possible by an innovation grant awarded by Tower Hamlets CCG