Screening electronic patient records to detect preventable harm: A trigger tool for primary care

Quality in Primary Care

Volumn 19, Issue 2, 2011, Pages 115-125

  De Wet, Carl ^b   Bowie, Paul ^a  

^a NHS EDUCATION FOR SCOTLAND   (United Kingdom)

^b NONE

Author keywords

Avoidable harm; Clinical audit; Electronic patient records; Learning; Patient safety; Quality improvement

Indexed keywords

ARTICLE; ELECTRONIC MEDICAL RECORD; HEALTH CARE QUALITY; HUMAN; MEDICAL ERROR; NATIONAL HEALTH SERVICE; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PRIMARY HEALTH CARE; SAFETY; UNITED KINGDOM;

CONTINUITY OF PATIENT CARE; GREAT BRITAIN; HUMANS; MEDICAL ERRORS; MEDICAL RECORDS SYSTEMS, COMPUTERIZED; PRIMARY HEALTH CARE; QUALITY OF HEALTH CARE; SAFETY MANAGEMENT; STATE MEDICINE;

EID: 79957493419     PISSN: 14791072     EISSN: 14791064     Source Type: Journal    
DOI: None     Document Type: Conference Paper

References (31)

1. Woloshynowych M, Neale G and Vincent C. Case record review of adverse events: a new approach. Quality and Safety in Health Care 2003; 12:411-15. (Pubitemid 37542020)
2. Vincent C, Neale G and Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-19. (Pubitemid 32230913)
3. Resar RK, Rozich JD and Classen D. Methodology and rationale for the measurement of harm with trigger tools. Quality and Safety in Health Care 2003; 12:39-45.
4. Neale G and Woloshynowych M. Retrospective case record review: a blunt instrument that needs sharpening. Quality and Safety in Health Care 2003;12:2-3. (Pubitemid 36241244)
5. Durkin N. Using record review as a quality improvement process. Home Healthcare Nurse 2006;24:492-502.
6. Wolff AM and Bourke J. Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review. Emergency Medicine Journal 2002; 19:35-40. (Pubitemid 34092535)
7. Olsen S, Neal G, Schwab K et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Quality and Safety in Health Care 2007; 16:40-4. (Pubitemid 46347949)
8. Szekendi MK, Sullivan C, Bobb A et al. Active surveillance using electronic triggers to detect adverse events in hospitalized patients. Quality and Safety in Health Care 2006;15:184-90.
9. Griffin FA and Classen DC. Detection of adverse events in surgical patients using the trigger tool approach. Quality and Safety in Health Care 2008; 17:253.
10. Resar RK, Simmonds T and Haraden CR. A trigger tool to identify adverse events in the intensive care unit. Joint Commission Journal on Quality and Patient Safety 2006; 32:585-90.
11. Sharek PJ, Horbar JD, Mason W et al. Adverse events in the neonatal intensive care unit: development, testing and findings of a NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics 2006; 118: 1332-40. (Pubitemid 46393776)
12. Scottish Government. Scottish Patient Safety Alliance. www.patientsafetyalliance.scot.nhs.uk (accessed 29 March 2008).
13. Rushmer R and Voigt D. Measure it, improve it: the Safer Patients Initiative and quality improvement in subcutaneous insulin therapy for hospital in-patients. Diabetic Medicine 2008;25:960-7.
14. NHS Institute for Improvement and Innovation. Primary Care Trigger Tool, www.institute.nhs.uk/safer- care/primary-care-2/ introductiontoprimarycaretriggertool.html (accessed 15 October 2010).
15. De Wet C and Bowie P. A preliminary study to develop and test a global trigger tool to identify undetected error and patient harm in primary care records. Postgraduate Medical Journal 2009;85:176-80.
16. NHS Quality Improvement Scotland. Safety Improvement in Primary Care, www.nhshealthquality.org/nhsqis/8079.html (accessed 15 October 2010).
17. Griffin FA and Resar RK. IHI Global Trigger Tool for Measuring Adverse Events 2e. IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement, 2009. www.IHI.org
18. NHS Education for Scotland. Guidance on Applying the Primary Care Trigger Tool. www.nes.scot.nhs.uk/sea (accessed 15 October 2010).
19. Graphpad Software. Random Number Generator. 2008. www.graphpad.com/ quickcalcs/randomN1.cfm (accessed 19 February 2009).
20. National Coordination Council for Medication Error Reporting and Prevention. Index for Categorising Medication Errors. Rockville, MD: NCC MERP, 2001.
21. Institute of Medicine. To Err is Human: building a safer health system. Washington, DC: National Academy Press, 1999.
22. Department of Health. An Organisation with a Memory: report of an expert group on learning from adverse events in the NHS. London: HMSO, 2000.
23. Department of Health. Doing Less Harm: improving the safety and quality of care through reporting, analysing and learning from adverse incidents involving NHS patients. Key requirements for health care providers. London: Department of Health, 2001.
24. World Health Organization. Patient Safety Research: better knowledge for better care. Geneva: WHO, 2009.
25. Rushmer R and Davies HTO. Unlearning in health care. Quality and Safety in Health Care 2004;13:ii10-15. (Pubitemid 39627117)
26. Bowie P and Pringle M. Significant Event Audit: guidance for primary care teams, www.nrls.npsa.nhs.uk/resources/?entryid45=61500 (accessed 30 April 2010).
27. Institute for Healthcare Improvement. Using the Plan-Do-Study-Act Cycle.www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/HowToImprove/ ChronicTestingChanges.htm (accessed 20 October 2010).
28. National Patient Safety Agency. National Reporting and Learning System. www.nrls.npsa.nhs.uk (accessed 18 October 2010).
29. Bowie P, Pope L and Lough M. A review of the current evidence base for significant event analysis. Journal of Evaluation in Clinical Practice 2008;14:520-36.
30. McKay J, Bowie P and Lough M. Variations in the ability of general medical practitioners in applying two methods of clinical audit: a five-year study of assessment by peer review. Journal of Evaluation in Clinical Practice 2006;12:622-9. (Pubitemid 44715471)
31. National Patient Safety Agency Quarterly Data Report. November 2009. www.nrls.npsa.nhs.uk/resources/type/data-reports/?entryid45=65320 (accessed 27 September 2010).