Safety incidents are extremely rare in primary care, but they do happen. Concerns have been raised about the safety of remote triage and remote consultations.
Rare safety incidents (involving death or serious harm) in remote encounters can be traced back to various clinical, communicative, technical and logistical causes. Telephone and video encounters in general practice are occurring in a high-risk (extremely busy and sometimes understaffed) context in which remote workflows may not be optimised. Front-line staff use creativity and judgement to help make care safer.
As remote modalities become mainstreamed in primary care, staff should be trained in the upstream causes of safety incidents and how they can be mitigated. The subtle and creative ways in which front-line staff already contribute to safety culture should be recognised and supported.
Journal article information
- Journal of publication: BMJ Quality and Safety
- Nuffield Trust contributors: Dr Rebecca Rosen and Nina Hemmings
- All authors: Payne R, Clarke A, Swann N, van Dael J, Brenman N, Rosen R, Mackridge A, Moore L, Kalin A, Ladds E, Hemmings N, Rybczynska-Bunt S, Faulkner S, Hanson I, Spitters S, Wieringa S, Dakin FH, Shaw SE, Wherton J, Byng R, Husain L and Greenhalgh T
- Volume: 2023
- Issue: 0
- Page range: 1–14. doi:10.1136/bmjqs-2023-016674
Abstract
Background
Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. Setting and sample UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021–2023.
Methods
Multimethod qualitative study. We explored causes of real safety incidents retrospectively (’Safety I’ analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often (’Safety II’ analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts.
Results
Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex 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. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions.
Conclusion
While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.