We describe the evolving development of a trigger review process as part of a pilot national safety improvement programme, which enables primary care clinicians to rapidly search electronic patient records to identify latent risks and previously undetected adverse events.
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References
1.
GriffinFA, ResarRK.IHI Global Trigger Tool for measuring adverse events. IHI Innovation Series. Cambridge (MA): Institute for Healthcare Improvement, 2007
2.
GoodVS, SaldanaM, GilderR, NicewanderD, KennedyDA.Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterization of adverse events to support patient safety learning opportunities. BMJ Qual Saf2011;20:25–30
3.
The Scottish Government. Delivering quality in primary care national action plan: implementing the Healthcare Quality Strategy for NHS Scotland. The Scottish Government, Edinburgh2010:1–18
4.
National Patient Safety Agency. Seven Steps to Patient Safety in Primary Care: the full reference guide. London: NPSA, 2006
5.
NHS Institute for Innovation and Improvement. The Primary Care Trigger Tool. http://www.institute.nhs.uk/safer_care/primary_care_2/background.html (last accessed 27 November 2011)
6.
Good Practice Wales. The Development of a Global Trigger Tool for Primary Care. http://www.goodpracticewales.com/Article.aspx?ArticleID=20456 (last accessed 27 November 2011)
7.
WalsheK.Pseudoinnovation: the development and spread of healthcare quality improvement methodologies. Int J Qual Health Care2009;21:153–9
8.
de WetC, BowieP. A preliminary study to develop and test a global trigger tool to identify undetected error and patient harm in primary care records. Postgraduate Medical Journal2009;85:176–80
9.
de WetC, BowieP. Screening electronic patient records to detect preventable harm: a trigger tool for primary care. Quality in Primary Care2011;19:115–25
10.
Healthcare Improvement Scotland. Patient Safety in Primary Care. 2011; available at: http://www.healthcareimprovementscotland.org/programmes/patient_safety/patient_safety_in_primary_care.aspx (last accessed 7 September 2011)
11.
Hippisley-CoxJ, FentyJ, HeapsM.Trends in consultation rates in general practice 1995 to 2006: analysis of the QRESEARCH database. The Information Centre,2007
12.
KostopoulouO, DelaneyBC, MunroCW.Diagnostic difficulty and error in primary care – a systematic review. Fam Pract2008;25:400–13
13.
SturmbergJP.Systems and complexity thinking in general practice: part 1 – clinical application. Aust Fam Physician2007;36:170–3
14.
SandarsJ, EsmailA.The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract2003;20:231–6
WetzelsR, WoltersR, van WeelC, WensingM.Mix of methods is needed to identify adverse events in general practice: a prospective observational study. BMC Fam Pract2008;9:35
17.
ThomasEJ, PetersenLA.Measuring errors and adverse events in health care. J Gen Intern Med2003;18:61–7
18.
LINNEAUS Euro-PC. Learning from international networks about errors and understanding safety in primary care. 2011; available at: http://www.linneaus-pc.eu/ (last accessed 7 September 2011)
19.
Institute for Healthcare Improvement. The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series White Paper 2003
20.
WoloshynowychM, NealeG, VincentC.Case record review of adverse events: a new approach. Quality & Safety in Health Care2003;12:411–5
21.
BenningA, GhalebM, SuokasA, Large-scale organizational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ2011;342:d195
22.
BennJ, BurnettS, ParandA, Studying large-scale programmes to improve patient safety in whole care systems: challenges for research. Soc Sci Med2009;69:1767–76
23.
BoskCL, Dixon-WoodsM, GoeschelCA, PronovostPJ.The art of medicine: reality check for checklists. The Lancet2009;374:444–5