Inappropriate Telephone Triage in Primary Care

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´╗┐Inappropriate Telephone Triage in Primary Care

Abstract and Introduction


Purpose: Our objective was to assess and categorize harm occurring to patients who called their physicians' office after-hours but did not have their call forwarded to the physician because they stated that their call was not an emergency.
Methods: We collected data on 4949 calls handled by our answering service for 1 year in a family medicine residency office in Denver, CO. Of the 2835 after-hours clinical calls, we reviewed all 288 clinical calls that were not forwarded to the "on-call" physician. Complete data on 119 clinical calls included reason for call, frequency of next day appointments, Emergency Department visits, hospital admissions and outcomes. Outcomes were reviewed and coded for harm to the patient by experienced medical errors coders.
Results: When patient calls were not forwarded, 51% had an appointment, 4% an Emergency Department visit, and 2% were admitted to the hospital within 2 weeks. Analysis revealed that 3% suffered harm, and 26% experienced discomfort due to the delay. Although 66% required no intervention, 1% required emergency transport and 4% a medication change.
Conclusions: Harm may occur when patients' calls are not forwarded to the on-call physician. Although the level of harm is generally temporary and minimal, the potential exists for serious harm to occur. Physicians need to re-evaluate the way they handle after-hours calls.


Over the past 10 years, the majority of studies of patient safety have focused on the hospital setting. A great deal of time, money, and energy has been spent identifying types of errors and system problems. The frequency of errors has varied from 6% to 18% with only a small portion of those errors resulting in permanent harm or death to the patients treated. Naturally, serious harm has garnered the most attention. Recently, attention has been focused on the ambulatory care settings, where errors may be even more frequent. For example, in the ambulatory care setting, adverse drug events may occur at a rate that is 4 times higher than that found in the hospital setting.

Attempts to classify the types of errors that occur in the ambulatory care setting have evolved in the past few years. Preliminary attempts focused on broad categories of errors such as "gaps in knowledge," "administrative failure," "treatment delivery lapse," and "miscommunication." Applied Strategies for Improving Patient Safety (ASIPS) used a detailed, multi-axial taxonomy containing 10 axes within 4 domains to code safety events. The overall ASIPS project developed and implemented an ambulatory primary care error reporting system, received and analyzed error reports, and implemented interventions to improve patient safety. Analysis of error reports submitted to ASIPS indicated that communication problems represented the most frequent error process within the ambulatory care setting. Furthermore, the failure to complete communication between providers and patients was associated with an increased risk of clinical harm.

We conducted a series of studies focusing on the after-hours telephone calls that patients make to physicians' offices. We have documented the frequency and nature of these calls, described patients who call frequently, and identified barriers to adequate patient-physician communication in current telephone triage systems. Our previous study of offices in the Denver, CO metropolitan area found that two-thirds of primary care offices used an answering service, and 93% of these offices required the patient to decide if their problem was an "emergency." In examining the calls triaged by patients, 90% were forwarded to the on-call physician but 10% were not. A panel of physicians who reviewed these calls reported they would have wanted to talk to the patient that evening in over 50% of the calls. In the present study, we have combined resources with the ASIPS staff to evaluate the actual clinical outcomes for patients who decided their problem was not an emergency and whose phone calls were not forwarded to the on-call physician.

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