The Primary Care Trigger Tool
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1 The Primary Care Trigger Tool Example of a General Practice Medical Record Ms. Annette Curtain, D.O.B. 01/01/1935 This fictional medical record is intended to be used as part of the practical training in the use of the trigger tool method. It purposefully imitates an authentic printed summary sheet that the vast majority of practices generate on a daily basis. The correspondence and investigation results that are included have been designed to represent printed copies of documents as they would commonly be used in Scotland s general medical practices. The following should be taken into consideration when attempting a review: Review only the three full calendar months February-April 2010 The maximum time limit of this exercise should be twenty minutes Record extracted data on a trigger tool proforma. Incidental findings and descriptions can be entered into the space provided. The trigger tool process is described in a separate guide. Some of the key points were: The focus is harm, not error. You do not necessarily have to find every trigger. Most harm incidents will have more than one trigger helping to detect it. The trigger tool review process may be facilitated by remembering five questions: Can a trigger(s) be detected? Did harm occur? What was the severity of the harm? Was the harm incident preventable? Where did the harm incident originate? A full discussion of the practical findings of this case, including the number and type of triggers and harm events are available. Disclaimer This complete medical record is fictional. It was created by NHS Education Scotland to support training in the use of the Trigger Tool method. The patients, healthcare professionals, providers and all other persons referred to are entirely fictional. Any resemblance to any person (living or dead) is entirely unintentional. This training material is the property of NHS Education Scotland and may be used free of charge on request from nes@nes.scot.nhs.uk NHS Education Scotland The Primary Care Trigger Tool: Clinical case study
2 Registration Mrs. Annette Curtain Service Code: Temporary Resident 39 Main Street D0B: 01/01/1935 FORTH, LANARK Age: 75 Telephone: Contact: Mrs. Jones ContactRelship: Daughter ? CHI Number: NHS Number:? Dispensing: No Patient ID: Road: 0 Water: 0 FootPath: 0 Occupation: Pensioner Marital Status: Single Registered GP: Dr Carl De Wet Seen By GP: Dr Carl De Wet Repeat Consultation:? Acute Consultation: 02/06/2010 Registered: 01/09/2009 Confirmed: 14/09/2009 Records Received:27/09/2009 BMI: 33.7 Height: 1.57 m Weight: 83kg BP: 142/78 Parity: 1 Gravida: 2 SCI-DC Consent Given: Yes Priority Clinical I User Marker Date Recorded Start Date Priority Description Modifier 06/05/2010 None High Allergic drug reaction NOS Freetext: Cocodamol 17/02/2010 None High Allergic drug reaction NOS Freetext: Amlodipine 30/09/2009 None High Hypertensive disease 04/05/2007 None High H/O: diabetes mellitus Freetext: diet controlled Repeat Medication Intervals Drug/Preparation Quantity/Dose/Frequency Start Last Pres. Review CMS Int. Ramipril TABS 2.5MG 28 one tab dly 02/06/ /06/ d 52w w. Paracetamol TABS 500MG tabs 4x day 02/06/ /06/ d 52w w. Adverse Reactions Read Code Description SN52. Drug hypersensitivity NOS 17/02/2010 ADR Description Amlodipine SN52. Drug hypersensitivity NOS 06/05/2010 ADR Description Cocodamol Summary sheet: All Sections Printed at 14/06/2010, 16: NHS Education Scotland Page 2
3 Clinical I User Marker Date Recorded Start Date Priority Description Modifier 03/03/2010 None Low Alcohol intake within recommended sensible limits 03/03/2010 None Low Assessing cardiovascular risk using SIGN score 03/03/2010 None Low Avoids even trivial exercise 03/03/2010 None Low Ex smoker 03/03/2010 None Low FH: Diabetes mellitus in first degree relative 03/03/2010 None Low Influenza vaccination 03/03/2010 None Low Lifestyle counseling 03/03/2010 None Low No FH: lschaemic heart disease 03/03/2010 None Low Pneumococcal vaccination contraindicated 03/03/2010 None Low Smoking cessation advice 09/09/2008 None Low Medication review done 07/09/2008 None Low Consent given for pandemic influenza vaccination 07/09/2008 None Low PANDEMRIX - first influenza A(H1N1v) 2009 vac given 07/09/2008 None Low Fast alcohol screening test 07/09/2008 None Low Pneumococcal vaccination given 07/09/2008 None Low Influenza vacc consent given 07/09/2008 None Low Influenza vaccination Left Arm - Batch Number: S31 Exp: 6/10 07/09/2008 None Low Smoking cessation advice given Last Encounter Lorraine Urquhart Date: 02/06/2010 General review - BP 145/85. Plan - bloods done. D/W GP and increase Ramipril to 2.5 mg dly = pt has her own supply and will double dose Acute Prescriptions Drug/Preparation Quantity/Dose/Frequency Date Flucloxacillin CAPS 500MG 28 one cap 4x day 12/03/2010 Ramipril CAPS 1.25MG 28 one caps dly 22/03/2010 Co-Codamol 3Omg/500mg TABS 60 1 or 2 Tabs every 4 to 6 hours 05/05/2010 Paracetamol TABS 500MG 50 1 or 2 Tabs 06/05/2010 Ramipril CAPS 10MG 28 1 cap daily 17/02/2010 Amlodipine TABS 5MG 28 one tab dly 05/02/2010 Summary sheet: All Sections Printed at 14/06/2010, 16: NHS Education Scotland Page 3
4 Inactive Repeat Drugs Drug/Preparation QuantitylDoselFrequency Start Last Pres Review CMS Int. Bendroflumethiazide TABS 2.5MG 56 1 Tab in the morning 09/09/ /02/ d 26 w. Ramipril TABS 10MG 28 one tab dly 17/02/ /02/ d 52w w. Screening None Referrals Date Rec Priority Ref. appt Provider Specialty Reason for referral Ref. by Attendance type Acute/Inactive Care Management Type Name Last Review Recall Next review Num Session Acute 1 st SPICE Index 02/06/2010 N/A N/A 1 Chronic SPICE smoking 02/06/2010 Inactive 1 Chronic SPICE basic health values 02/06/2010 Inactive 1 Chronic SPICE hypertension 02/06/2010 Inactive 1 Chronic SPICE Diabetes 02/06/2010 Inactive 2 Palliative Care Associates Title Forename Surname Relationship Relationship Type Associate Of Title Forename Surname Relationship Relationship Type Clinical Values Date Value Type Value 03/03/2010 Diastolic 78 09/09/2008 Height /03/2010 Systolic /03/2010 Weight 83 Summary sheet: All Sections Printed at 14/06/2010, 16: NHS Education Scotland Page 4
5 F3 Clinical Notes Date Con Prov F3 Clinical Notes 02/06/2010 PN General review - BP 145/85. Plan - bloods done. D/W GP and increase Ramipril to 2.5 mg dly = pt has her own supply and will double dose 28/05/2010 GP Pain in knee persists. Unable to sleep and generally fed up. Exam - as before Plan - advised on physio self-referral. Consider orthopaedic referral if no improvement 06/05/2010 GP Tried Cocodamol, but faint/dizzy and generally unwell. Plan - stop. regular Paracetamol 05/05/2010 GP Pain in left left knee for 1/52, with assoc stiffness Ex - normal gait, reduced ROM but no effusion, crepitus IMp - OA Plan - Cocodamol 04/04/2010 PN BP 150/80 Plan - increase ramipril to 2.5 mg dly, UCE checked 22/03/2010 GP See prey entries - UCE normal, BP 160/95 x2. Plan - restart Ramipril 1.25 mg and review with PN - titrate carefully 19/03/2010 PN Wrist redness now almost completely gone - bruising on arms fading. BP 145/85, Bloods done 15/03/2010 GP Redness wrist resolving, but copious diarrhoea -tolerating fluids. Imp: likely AAD Plan - stop Flucloxacillin, review if needed 12/03/2010 GP See prey entry - Ex: left arm tracking, redness and tenderness. Systemically stable. Imp - cellulitis, sec to IVI Plan - oflucloxacillin 12/03/2010 GP Review phone call. Patient discharged from hospital - much better but concerned redness and pain left wrist?ivi site Plan - review (HV) 04/03/2010 GP Weakness, fatigue and occasional palpitations. Lives alone with daily, private home help Ex - BP 120/75, p55r, respiration clear, mobilizing but staggering. Imp - likely hyperkalaemia Plan - d/w MOC and admit for observation 03/03/2010 GP Lab phoned with blood results - K=6.5, non-haemolyzed. Plan - phone patient - no response 03/03/2010 PN BP 135/75. Bloods taken as per GP request for UCE, egfr. SPICE done 17/02/2010 GP See prey entry - unacceptable, bilateral ankle swelling. Ex - BP 150/88 l=r Imp - oedema sec to Amlodipine Plan - discontinue and start ACE, with PN f/u for UCE 2/52 05/02/2010 GP Bilateral, dull headaches, worsening over last few weeks. Ex- BP 170/90 sit=stand x2 readings Imp - uncontrolled hypertension Plan - add amlodipine, review 2/52 09/09/2008 GP High BPs x3 - referred by PN. Plan - commence diuretic 07/09/2008 PN BP 165/95, 175/105. SPICE, general advice will make appt to see GP to discuss blood pressure Summary sheet: All Sections Printed at 14/06/2010, 16: NHS Education Scotland Page 5
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