In this study on medical errors in PCEUs in Norway patient complaints have been used as an outset. A group of complaint evoking physicians and a random sample of physicians from the same PCEU and time period, were analyzed. In assessing the content of the medical records, the essential finding was the significance of the gender of the physicians. Male physicians in the complaint group were judged to have the lowest proportion of no-error and the highest proportion of records being inconclusive for management assessments compared to their female colleagues. Inconclusiveness was considered when incomplete documentation was detected without judging the deficiencies as crucial for assessing the medical performance.
Physician training expressed by seniority or GP specialty, did not have significant implications. Neither did we find any association between medical errors and any of the chosen variables. This is partly unlike the findings in our study on patient complaints, where having GP specialty or a workload of more than one duty in the fourteen-day period, significantly reduced the risk of complaint evoking (11). As complaints and errors may be considered complementary or supplementary, the lack of concurrence in the results of our studies is surprising. However, as a complaint is written in retrospect, the medical record should be the basis for the assessments. The physician’s attitude may induce a complaint. In this study complaints on physician’s behaviour were not included.
A conceivable reason for not confirming the advantageous effect of the GP specialty, may be the overall effect of the Norwegian qualification requirements for unrestricted working in a PCEU (16). In addition to this a course on emergency medicine has since 2012 been required for being qualified as a GP specialist (16). This may be of decisive importance while 57.6% of the physicians in the random sample group had this specialty, and the additional number of physicians in training for being qualified is unknown.
The effect of structured training is well known (2,24,25). In this line it should be expected that the experience caused by increasing seniority, may have the protective function against medical errors. Nevertheless, studies have shown that increasing seniority increases the incidence of medical errors (13,14). The reason for the lack of this effect in our study, may once again be the Norwegian system requiring a post-educational program for unrestricted working in a PCEU (16).
Being on-call is about getting to know the specific professional issues, acquiring the appropriate knowledge on facilities and co-working. In this way a high workload has been shown to act as training for the physicians, thereby providing a protection against complaint evoking (11). In this context it should be expected that having more than one duty during a fourteen-day period, would achieve the effect of training. This effect is not reached in this study on medical errors.
Language skills and cultural competence have been shown as a prerequisite for satisfactory communication, avoiding unfortunate events (12,13). Physicians not having a Norwegian citizenship, may have their communication skills influenced by their mother tongue and a diverging approach on cultural basis in communicating with patients. Nevertheless, in studying patient complaints, citizenship did not seem to be of importance (11). These compatible results for physicians with or without Norwegian citizenship, may once more be explained by the Norwegian prerequisites for working in a PCEU and the required course on emergency medicine for getting qualified as a GP specialist (16). The consequence of these regulations coincides with the results of a study including graduates from foreign versus US medical schools, showing better patient outcome with graduates from foreign schools (26). This is explained by a rigorous approach to incorporate international medical graduates.
It is intriguing that for only 53.2% of the patients in the complaint group a medical error was uncovered. This is consistent with a Norwegian study on medicolegal assessments (10). However, this does not support an assertion that nearly half of the complaints were unfounded. In the same way disclosing sparse recording does not necessarily lead to the conclusion that the medical measures have been erronous. As medical records in PCEUs often will not document the complete course of events, this inconclusiveness may be hiding deficiencies in managing the patients. These deficiencies may be seen as the main reason for the proportion of medical records assessed as inconclusive in this study, i.e. making it inadequate to decide whether or not a medical error could have or had led to patient harm. The finding that only 3% of the medical records in the random sample group revealed medical errors, is consistent with larger studies from primary health care (1,8). The low sample size does not allow any statistical assessments for this group.
The proportion of inconclusive medical records was similar in the complaint and the random sample group (29.9 and 27.6%). The gender difference exclusively related to no-error and inconclusive assessments, may be explained by female physicians being more thorough in journaling.
Further research is needed on disclosing the course of actions in managing patients in PCEUs. This means studying the underlying elements in the physician’s considerations and decisions documented in the medical record. Hereby including any additional notes revealing information that might have been available to the physician.
Strength and limitations
The strength of this study is that it is based on a case-control design with a proper random sample group with valid and nearly complete data sets. The proportion of inconclusive medical records was similar in the complaint group and the random sample group (29.9 and 27.6%). This substantiates the assumption of consistency in the assessments of the medical records in the two groups. Knowing about the complaints does not seem to have influenced the judgements. The use of a normative tool, fascilitated consistency in rewiewing the medical records (17).
The main weakness of the study is the unexpected low number of medical records included. There were different reasons for this low number: compatibility problems with the customized data extraction programme and the different electronic medical record systems, changing leadership during the study period at some PCEUs together with heavy workload. The lack of electronic compatibility was the essential reason for one of the larger units. Broad scale extraction of textual material from different electronic medical record systems, is at present still not possible. The low number of medical records create limitations on the application of the results of this study.
As smaller units with rather few participating physicians were included, the frequency of duties increases the probability to be picked up as a control more than once. This may be a bias in this study, reflected by the lower number of individual physicians than should be expected from the number of cases. This does not seem to have influenced the results.