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Patient Safety in Remote Primary Care Encounters: Combined Safety I and Safety II Analysis

84 Pages Posted: 16 Aug 2023

See all articles by Rebecca Payne

Rebecca Payne

University of Oxford

Aileen Clarke

University of Oxford

Nadia Swann

University of Oxford

Sietse Wieringa

University of Oslo

Jackie Van Dael

University of Oxford

Natassia Brenman

University of Oxford

Rebecca Rosen

Queen Mary University of London - NHS Trust

Adam Mackridge

Betsi Cadwaladr University Health Board

Lucy Moore

University of Oxford

Asli Kalin

University of Oxford

Francesca Dakin

University of Oxford

Sara Shaw

University of Oxford

Emma Ladds

University of Oxford

Nina Hemmings

Queen Mary University of London - NHS Trust

Joseph Wherton

University of Oxford

Richard Byng

University of Plymouth - Community and Primary Care Research Group

Sarah Rybczynska-Bunt

University of Plymouth

Stuart Faulkner

University of Oxford

Isabel Hanson

University of Oxford

Laiba Husain

University of Oxford

Trish Greenhalgh

University of Oxford

More...

Abstract

Background: Triage and consultations increasingly occur remotely (telephone, video or online). Safety concerns have been raised.

Aim: To learn why safety incidents occur in remote encounters and how they could be prevented.

Design and setting: UK primary care. Mixed-method study including incident analysis and ethnography.

Methods: Safety incidents in remote triage or consultations, comprising complaints (n = 69), closed indemnity claims (n = 16) and reports (n = 10), were coded independently by two researchers and systematically fictionalised. Culture and safety practices of in-hours general practice were explored via ethnography in 12 practices followed from 2021-2023 plus additional interviews with out-of-hours providers, trainers and trainees. Data were analysed thematically using Safety I (safety incidents) and Safety II (safety culture) frameworks. Preliminary interpretations were checked with stakeholders in safety-strategic roles before finalising.

Results: Safety incidents in remote encounters were characterised by inappropriate choice of modality, poor rapport-building, inadequate information-gathering, limited clinical assessment, inappropriate clinical pathway (e.g. wrong algorithm) and failure to take account of social circumstances. These in turn led to missed, inaccurate or delayed diagnoses, under-estimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety-netting and inadequate follow-up. Patients with complex or multiple pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment, or difficulty communicating seemed especially vulnerable. Ethnographic analysis revealed a high-risk context: remote encounters were occurring in a system under pressure, with resource constraints, under-staffing and high demand. Triage and care pathways were complex and hard to navigate; they involved distributed work among multiple clinical and non-clinical staff. Front-line staff often made remote care safer by playing hunches and creative workarounds.

Conclusion: Safety errors are rare in remote primary care but deaths and serious harms have resulted. We offer suggestions for patient-, staff- and system-level mitigations.

Funding: The main funding for this study was for the Remote by Default 2 study (NIHR, grant number 132807). Additional funding was from the ModCons study (NIHR School of Primary Care Research, grant no 594). Salaries of academic fellows were supported by NIHR (RP, AK), Wellcome Trust (EL), NIHR School of Primary Care Research (FD), European Commission (SW) and THIS Institute (LH).

Declaration of Interest: RP was National Professional Advisor, Care Quality Commission from 2017 to 2022. She received £200 speaking fee from Cogora for speaking on reducing patient complaints at the Management in Practice conference, Birmingham 2023. All other authors declare no competing interests.

Ethical Approval: Ethical approval was granted by the East Midlands—Leicester South Research Ethics Committee and UK Health Research Authority (September 2021, 21/EM/0170 and subsequent amendments). Access to the NHS Resolution dataset was obtained by secondment of the RP via honorary employment contract, where she worked with staff to de-identify and fictionalise relevant cases. Oversight was provided by an independent advisory group with a lay chair and patient and lay representation.

Keywords: remote consulting, digital health, video, telephone, risk, safety, primary care

Suggested Citation

Payne, Rebecca and Clarke, Aileen and Swann, Nadia and Wieringa, Sietse and Van Dael, Jackie and Brenman, Natassia and Rosen, Rebecca and Mackridge, Adam and Moore, Lucy and Kalin, Asli and Dakin, Francesca and Shaw, Sara and Ladds, Emma and Hemmings, Nina and Wherton, Joseph and Byng, Richard and Rybczynska-Bunt, Sarah and Faulkner, Stuart and Hanson, Isabel and Husain, Laiba and Greenhalgh, Trish, Patient Safety in Remote Primary Care Encounters: Combined Safety I and Safety II Analysis. Available at SSRN: https://ssrn.com/abstract=4538231 or http://dx.doi.org/10.2139/ssrn.4538231

Rebecca Payne

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Aileen Clarke

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Nadia Swann

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Sietse Wieringa

University of Oslo ( email )

PO Box 6706 St Olavs plass
Oslo, N-0317
Norway

Jackie Van Dael

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Natassia Brenman

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Rebecca Rosen

Queen Mary University of London - NHS Trust ( email )

Adam Mackridge

Betsi Cadwaladr University Health Board ( email )

Lucy Moore

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Asli Kalin

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Francesca Dakin

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Sara Shaw

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Emma Ladds

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Nina Hemmings

Queen Mary University of London - NHS Trust ( email )

Joseph Wherton

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Richard Byng

University of Plymouth - Community and Primary Care Research Group ( email )

Plymouth
United Kingdom

Sarah Rybczynska-Bunt

University of Plymouth

Drake Circus
Plymouth, PL22QZ
United Kingdom

Stuart Faulkner

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Isabel Hanson

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Laiba Husain

University of Oxford ( email )

Mansfield Road
Oxford, OX1 4AU
United Kingdom

Trish Greenhalgh (Contact Author)

University of Oxford

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