Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement

Abstract

Objectives: To report the implementation of a trigger review method (TRM) in primary care, with a particular focus on its impact on patient safety-related findings.

Design: Cross-sectional structured review of random samples (n=25) of electronic records of 'high-risk' patient groups conducted twice per year (each for a retrospective review period of 3 months).

Setting: 274 general practices in two regions of Scotland.

Intervention: Contractual incentivisation of TRM implementation.

Main outcome measures: Practice participation rate; characteristics of patient safety incidents (PSIs), for example, their prevalence, type, perceived severity and preventability; and actions or intended actions undertaken during and after trigger reviews.

Results: 274 of 318 eligible practices (86.2%) returned 536 TRM Summary Reports, which outlined findings from reviews of 13 351 electronic patient records. 1887 (14.1%) PSIs were recorded, with a mean of 3.5 (536/1887) per Summary Report (SD±1.6). Of these, 830 (44.0%) were judged to have caused mild to moderate harm, with 262 (13.9%) cases resulting in more severe harm. A total of 852 PSIs (46.2%) were rated as preventable or potentially preventable. In 459 Summary Reports (85.6%), reviewers indicated implementing one or more improvement actions during the actual TRM process; and 2177 actions after completion of the TRM process (mean 4.1 (SD±3.3) actions per review).

Conclusions: The great majority of clinician reviewers 'successfully' applied the TRM, uncovering important but previously undetected PSIs, which prompted care teams to take action during and after the trigger reviews. The method and data generated have the potential to drive improvements in related care processes at the practice, regional and national health system level. TRM arguably increased 'ownership' of the safety challenge and clinician engagement in implementing their solutions to specific problems identified. Our results suggest that the TRM has potential as a feasible, pragmatic approach to improving primary care safety and quality.

Keywords: General practice; Medical error, measurement/epidemiology; Patient safety; Primary care; Quality improvement.