Rebecca Payne, Aileen Clarke, Nadia Swann, Jackie van Dael, Natassia Brenman, Rebecca Rosen, Adam Mackridge, Lucy Moore, Asli Kalin, Emma Ladds, Nina Hemmings, Sarah Rybczynska-Bunt, Stuart Faulkner, Isabel Hanson, Sophie Spitters, Sietse Wieringa, Francesca H Dakin, Sara E Shaw, Joseph Wherton, Richard Byng, Laiba Husain, Trisha Greenhalgh
{"title":"远程初级保健就诊的患者安全:多方法定性研究,结合安全性I和安全性II分析。","authors":"Rebecca Payne, Aileen Clarke, Nadia Swann, Jackie van Dael, Natassia Brenman, Rebecca Rosen, Adam Mackridge, Lucy Moore, Asli Kalin, Emma Ladds, Nina Hemmings, Sarah Rybczynska-Bunt, Stuart Faulkner, Isabel Hanson, Sophie Spitters, Sietse Wieringa, Francesca H Dakin, Sara E Shaw, Joseph Wherton, Richard Byng, Laiba Husain, Trisha Greenhalgh","doi":"10.1136/bmjqs-2023-016674","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them.</p><p><strong>Setting and sample: </strong>UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"573-586"},"PeriodicalIF":5.6000,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11347200/pdf/","citationCount":"0","resultStr":"{\"title\":\"Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis.\",\"authors\":\"Rebecca Payne, Aileen Clarke, Nadia Swann, Jackie van Dael, Natassia Brenman, Rebecca Rosen, Adam Mackridge, Lucy Moore, Asli Kalin, Emma Ladds, Nina Hemmings, Sarah Rybczynska-Bunt, Stuart Faulkner, Isabel Hanson, Sophie Spitters, Sietse Wieringa, Francesca H Dakin, Sara E Shaw, Joseph Wherton, Richard Byng, Laiba Husain, Trisha Greenhalgh\",\"doi\":\"10.1136/bmjqs-2023-016674\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them.</p><p><strong>Setting and sample: </strong>UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusion: </strong>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.</p>\",\"PeriodicalId\":9077,\"journal\":{\"name\":\"BMJ Quality & Safety\",\"volume\":\" \",\"pages\":\"573-586\"},\"PeriodicalIF\":5.6000,\"publicationDate\":\"2024-08-16\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11347200/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"BMJ Quality & Safety\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1136/bmjqs-2023-016674\",\"RegionNum\":1,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"HEALTH CARE SCIENCES & SERVICES\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"BMJ Quality & Safety","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1136/bmjqs-2023-016674","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis.
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.
期刊介绍:
BMJ Quality & Safety (previously Quality & Safety in Health Care) is an international peer review publication providing research, opinions, debates and reviews for academics, clinicians and healthcare managers focused on the quality and safety of health care and the science of improvement.
The journal receives approximately 1000 manuscripts a year and has an acceptance rate for original research of 12%. Time from submission to first decision averages 22 days and accepted articles are typically published online within 20 days. Its current impact factor is 3.281.