Learning from diagnostic error when primary care services are located in or alongside emergency departments: a theory generating mixed-methods study

Abstract

BackgroundNew healthcare service models are being introduced to help manage increasing demand on emergency healthcare systems including the provision of primary care services in or alongside emergency departments. There is little research evidence to guide decisions about how service models can be most effective and safe.AimFocusing on diagnostic error, the aim was to learn why errors occur to identify priority interventions.MethodTwo data sources were used to identify diagnostic error reports including: coroners’ reports to prevent future deaths; and the National Reporting and Learning System (NRLS). A cross-sectional, mixed-methods theory-generating study which used a multi-axial PISA classification system based on the recursive model for incident analysis, was carried out.ResultsNine Coroners’ reports (from a total of 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error with learning relevant to primary care services in or alongside emergency departments. Clinical presentations included musculoskeletal injuries; unwell infants; headaches; and chest pains. Findings highlighted a difficulty identifying appropriate patients for the primary care service; underinvestigation; misinterpretation of diagnostic tests; underuse of safeguarding protocols; and inadequate communication and referral pathways between the services.ConclusionPriority areas to minimise risk of diagnostic error when primary care services are located in or alongside emergency departments include clinical decision support to triage and stream patients to the appropriate care setting; contextualised, workplace-based education and training for primary care staff; and standardised computer systems, communication and referral pathways between emergency and primary care services.