TY - JOUR

T1 - Patient safety in remote primary care encounters

T2 - multimethod qualitative study combining Safety I and Safety II analysis

AU - Payne, Rebecca

AU - Clarke, Aileen

AU - Swann, Nadia

AU - van Dael, Jackie

AU - Brenman, Natassia

AU - Rosen, Rebecca

AU - Mackridge, Adam

AU - Moore, Lucy

AU - Kalin, Asli

AU - Ladds, Emma

AU - Hemmings, Nina

AU - Rybczynska-Bunt, Sarah

AU - Faulkner, Stuart

AU - Hanson, Isabel

AU - Spitters, Sophie

AU - Wieringa, Sietse

AU - Dakin, Francesca H

AU - Shaw, Sara E

AU - Wherton, Joseph

AU - Byng, Richard

AU - Husain, Laiba

AU - Greenhalgh, Trisha

N1 - © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.

PY - 2024/8/16

Y1 - 2024/8/16

N2 - 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.

AB - 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.

KW - Humans

KW - Patient Safety

KW - Primary Health Care

KW - Qualitative Research

KW - United Kingdom

KW - Longitudinal Studies

KW - Triage

KW - Prospective Studies

KW - Female

KW - Male

KW - Retrospective Studies

U2 - 10.1136/bmjqs-2023-016674

DO - 10.1136/bmjqs-2023-016674

M3 - Article

C2 - 38050161

VL - 33

SP - 573

EP - 586

JO - BMJ Quality & Safety

JF - BMJ Quality & Safety

SN - 2044-5415

IS - 9

ER -