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

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

Patient safety, Diagnostic error, General practitioners, Emergency department

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.

Alison Cooper, Andrew Carson-Stevens, Matthew Cooke, Peter Hibbert, Thomas Hughes, Faris Hussain, Aloysius Siriwardena, Helen Snooks, Liam J. Donaldson and Adrian Edwards

BMC Emergency Medicine

(2021) 21:139

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