Clinical case study discussion: Joe Bloggs, 01/01/1935

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1 Clinical case study discussion: Joe Bloggs, 0/0/935 Trigger tool findings The completed trigger tool proforma is shown in appendix and will be referred to throughout this discussion. The period of review was for the three full calendar months from February to April. It may be useful to consider this case by considering the same five questions (discussed in the trigger tool practical application guide) as the reviewer.. Can triggers be detected? Five different triggers can be detected. Some triggers can be detected more than once so that the total number is eight. 2. Did harm occur? There are at least two different incidents of harm: Incident : The patient suffered an allergic drug reaction secondary to Amoxicillin A traumatic knee effusion (haemarthroses) either causes or worsened by an abnormally elevated INR. There are three different triggers that could have helped the reviewer to detect each of these two incidents. Incident was signposted by a hospital admission, A+E attendance and INR > 5. Incident 2 was signposted by an A+E attendance, INR >5 and Hb < 0. Even if a reviewer found only one or two of the triggers that would still have been sufficient to achieve the main objective - to detect harm. Some reviewers may have detected a possible third harm event: the significant elevation of the patient s INR, likely as a result of his oral antibiotic. There are a number of reasons why this should arguably not be coded as a harm incident: The elevated INR could have been due to a different cause than the oral antibiotic. For example, the illness or excessive alcohol (a distinct possibility judging by the medical record s clinical read codes) The patient was hospitalized for a different reason before the INR incident could lead to harm He did not suffer temporary or permanent harm directly as a result of his elevated INR on that occasions specific intervention was needed. However, in a different scenario where the patient had to attend the surgery every second day for venepuncture / INR testing it should have been coded as harm.

2 3. What was the harm severity? Incident : This incident should be graded as an E (temporary harm to the patient - required intervention). Some reviewers might have considered F, but the patient was already hospitalized at this time it is unclear from the medical record if the reaction would have been severe enough to have led to an admission (although it might have been). However, if there is reasonable doubt the reviewer should always opt for the least severe grade. This incident should also be graded as an E (temporary harm to the patient - required intervention). If the patient s knee did not recover in due course and he continued to suffer pain and/or restricted activity it would then be graded as G (permanent patient harm). 4. Did the event originate in primary or secondary care? Incident : The vast majority of reviewers would indicate that this event originated in secondary care. This will be reconsidered in more detail below. This incident originated in primary care. Reviewers should try to establish the setting as well as the likely origin of the cause. 5. Was the harm preventable? Incident : The majority of reviewers would have found it difficult to be sure whether this event could have been prevented. The trigger tool method should be focused and rapid within these constraints it would have been acceptable to mark unsure. The preventability of this incident is also difficult to judge. The elevated INR could almost certainly have been prevented although it would be very difficult to prove. There are a number of risk factors and clinical observations in the record that suggests that the accidental fall may have been prevented- this will be considered in more detail below. 2

3 Acts of Omission The differences between acts of omission and commission and the role of the trigger tool method have been discussed before. There are several potential acts of omission in this case study:. Administrative clinical read code was entered when the patient suffered an allergic drug reaction secondary to Amoxicillin in This period was not under review. However, even if it was, none of the triggers would have helped the reviewer to detect it. This relatively minor administrative error did not have any immediate consequences but two years later the patient suffered a similar (or worse) adverse event. It is possible that if the event had been coded that it would have been included in the hospital referral letter and may have prevented this event. The ambiguity and uncertainty about various different scenarios help to illustrate why acts of omission can be very difficult to judge. Even if we assume that the second adverse event could not have been prevented, there is still a very important learning point for the reviewer and practice team. Some of the potential improvement initiatives in their practice include: Ensuring proper coding of all adverse drug events Enclosing histories of adverse drug events in all correspondence with secondary care Improving patient education regarding adverse drug events 2. Prescribing The patient is on the chronic obstructive pulmonary disease register. He has been treated on several occasions for infective exacerbations. On this occasion the patient was reviewed several times. The clinical notes show a deterioration (for example a respiratory rate that increases from 26 36/min) yet he was not prescribed Prednisolone. Again, it is unclear whether this would have prevented the eventual admission, although it is certainly possible. The patient was prescribed Ciprofloxacin. This would almost certainly not be the first line oral antibiotic in any Scottish health board. Although it can be effective, it has various potential side effects, resource implications and increases antibiotic resistance. 3. Chronic disease management The patient s blood pressure has been documented on several occasions throughout the medical record. There are several omissions: Failure to diagnose hypertension Failure to attempt to treat hypertension Failure to consider and potentially investigate for target organ damage and possible secondary causes. Failure to discuss (or at least document) the patient s preference regarding treatment. The patient also has hypercholesterolaemia and several additional cardiovascular risk factors. He would appear to be a suitable candidate for statin therapy. 3

4 4. entative medicine The patient suffered an accidental fall. There are a number of potential positive risk factors that increased this possibility: According to his medical record clinical read codes and prescribing section he suffers from glaucoma. The medical record does not provide information about his visual acuity. However, reduced visual acuity would predispose him to falls as well as incorrect medication use (one possible explanation for his high INRs) The patient was noted to be unsteady after his admission. Early referral to the community outreach team, physiotherapy or other services might have helped to prevent the fall. The patient is known to live alone. It is unclear from the records whether there are home adaptations that could have been made to help prevent a fall. 5. Missed diagnosis The patient had previously attended OOH with a history of haematemesis (blood-streaked sputum). During his hospital admission he had a chest x-ray with pathology and a recommendation for a follow-up. There is also proof in his medical record (clinical codes) of objective and significant weight loss over the last year and that he continues to smoke. All of these symptoms and signs collective suggest that the patient may very well have an undiagnosed pulmonary neoplasm. There are several potential learning points for the reviewer and team: Red flag symptoms noted in OOH/A+E correspondence should be followed up in the surgery Review the current system dealing with correspondence from secondary care Request an urgent repeat chest x-ray for the patient and/or consider urgent respiratory referral. 4

5 Trigger Tool Proforma General information Classification of severity Number of consultations Date of review 07/06/200 E Temporary harm to the patient - required intervention Time to review record 4 minutes F Temporary harm to the patient - required hospitalization Telephone GP - surgery Unique ID (CHI) G Permanent patient harm GP - home visit 0 H Required intervention to sustain life Practice nurse I Death of patient Other 8 0 Triggers Is Trigger present? Did harm occur? =recorded Severity? Harm origin??=unsure entable??=unsure 3 consultations in 7 days Prim? Sec? New high priority clinical read code Prim? Sec? New allergy read code Prim? Sec? Repeat medication item discontinued Prim? Sec? OOH / A+E attendance E Prim? Sec? Hospital admission E Prim? Sec? INR >5, <.8 Recorded Prim? Sec? Hb < 0.0 New Recorded Prim? Sec? AST/ALT > 50 New Prim? Sec? Summary of harm event(s). Amoxicillin administered in hospital suffered adverse drug reaction 2. Accidental fall Traumatic knee effusion (haemarthrosis). Likely worsened due to elevated INR 5