TRIGGER TOOL DATA PROFORMA
Review Date (DD/MM/YY) Review period (3 mths of review i.e. May - July)
Time to
Case review
Number (1- record Episode
20) (mins) number Triggers (Generic)
> 3 consultations in 7 days New 'high' priority read code or problem add
Trigger? Harm? Severity? Harm origin? Preventable? Trigger? Harm?
1 1
2 1
3 1
4 1
5 1
6 1
7 1
8 1
9 1
10 1
11 1
12 1
13 1
14 1
15 1
16 1
17 1
18 1
19 1
20 1
Report Summary
Total number of triggers 0
Total rates of harm 0
Total severity rating E 0
Total severity rating F 0
Total severity rating G 0
Total severity rating H 0
Total severity rating I 0
Harm origin Primary 0
Secondary 0
Unsure 0
Preventable Yes 0
No 0
Unsure 0
Total No. of each trigger:
>3 consultations in 7 days 0
New 'high' priority read code added 0
New allergy read code added 0
Repeat' medication item continued 0
OOH/ A+E attendance 0
Hospital admission 0
INR >5, 5, <1.8 Hb <10
Harm? Severity? Harm origin? Preventable? Trigger? Harm? Severity? Harm origin? Preventable? Trigger?
Hb <10 Drop in Egfr of 5
Harm? Severity? Harm origin? Preventable? Trigger? Harm? Severity? Harm origin? Preventable?
Brief description of harm event Why did harm occur? (this may need further analysis i.e.
SEA)
Incidental Findings 1 Incidental Findings 2 Incidental Findings 3
Action taken/ future areas for
improvement