Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis

Abstract

Background Increasing demand on emergency healthcare systems has prompted introduction of new healthcare service models including the provision of GP services in or alongside emergency departments. In England this led to a policy proposal and £100million (US$130million) of funding for all emergency departments to have co-located GP services. However, there is a lack of evidence for whether such service models are effective and safe. We examined diagnostic errors reported in patient safety incident reports to develop theories to explain how and why they occurred to inform potential priority areas for improvement and inform qualitative data collection at case study sites to further refine the theories. Methods We used a mixed-methods design using exploratory descriptive analysis to identify the most frequent and harmful sources of diagnostic error and thematic analysis, incorporating realist methodology to refine theories from an earlier rapid realist review, to describe how and why the events occurred and could be mitigated, to inform improvement recommendations. We used two UK data sources: Coroners’ reports to prevent future deaths (30.7.13–14.08.18) and National Reporting and Learning System (NRLS) patient safety incident reports (03.01.05–30.11.15). Results Nine Coroners’ reports (from 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error related to GP services in or alongside emergency departments. Initial theories to describe potential priority areas for improvement included: difficulty identifying appropriate patients for the GP service; under-investigation and misinterpretation of diagnostic tests; and inadequate communication and referral pathways between the emergency and GP services. High-risk presentations included: musculoskeletal injury, chest pain, headache, calf pain and sick children. Conclusion Initial theories include the following topics as potential priority areas for improvement interventions and evaluation to minimise the risk of diagnostic errors when GPs work in or alongside emergency departments: a standardised initial assessment with streaming guidance based on local service provision; clinical decision support for high-risk conditions; and standardised computer systems, communication and referral pathways between emergency and GP services. These theories require refinement and testing with qualitative data collection from case study (hospital) sites.

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): A tool for patient safety in hospitals

“…After screening and removing duplicates, 17 studies 13,15–30 that examined PFDs in England and Wales were included (Figure 3).…”

“…Eight studies (47%) explored PFDs describing medicines and drugs that had caused or contributed to deaths, 15,16,19,24–26,29,30 two studies assessed PFDs involving chemical products, including paraffin-based emollient creams and alcohol-based hand sanitisers, 21,28 one study examined PFDs involving diagnostic errors, 27 four publications explored healthcare-related PFDs, 17,18,20,22 and two studies analysed PFDs using a selection of categories from the Courts and Tribunals Judiciary website 13,23 (Table 1). Across these studies, preventable deaths often occurred in hospitals.…”

“…Cooper et al highlighted that PFDs report the most severe cases of harm and therefore may not offer generalisable lessons. 27 There is also the problem of timeliness, limiting how swiftly actions can be implemented, owing to the constraints of the coronial system; Ferner et al 25 found a median delay of 240 days from the date of death to the issue of a PFD. Despite the lag, the concerns in these PFDs still warrant wide public dissemination, to ensure that actions are accountably implemented.…”

“…In this narrative review, we identified 17 studies 13,[15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] that analysed PFDs in England and Wales. PFDs documenting deaths related to medicines and drugs were explored most (47%; n = 8), followed by deaths involving healthcare (24%; n = 4) and chemical products (12%; n = 2).…”

Paramedic To Provider Consultation Challenges in the Emergency Department in Kazakhstan: An Online Survey

“…11 Internal diseases require more careful differential diagnosis; the counseling process here can cause significant difficulties, sometimes leading to conflict situations. 12 It is known that conflicts with providers in the emergency care system can increase the number of medical errors, lead to poor patient outcomes, and dissatisfaction with doctors. Conflict situations are often associated with unprofessional and unethical behavior of medical staff.…”