Medical errors are reported as a malpractice claim, and it is (1) mandatory in Sweden for healthcare providers to report risk of medical errors and events that have led to or could have led to a medical error to the responsible authority (2). Healthcare providers are responsible for the investigation, e.g., for identifying factors contributing to the medical error and for facilitating learning from the medical error (3). Due to limited healthcare resources and politicians’ demands for cost reduction, nurse-led telephone advice nursing (here referred to as “telephone nursing”) is rapidly increasing. In Sweden, the national telephone nursing service Swedish Healthcare Direct (SHD) is recommended as the populations’ first contact with the healthcare system (4, 5). The aim of telephone nursing services is to provide increased accessibility to qualified healthcare advice and to rationalize use of limited healthcare resources (6, 7). Telephone nursing includes triage of care-seekers’ need for care, referral to the appropriate level of care, offering self-care advice and supporting care-seekers (5, 8). The telephone nurses independently triage care-seekers’ need for care using the mandatory assistance of a computerized decision support system (CDSS)(9, 10). The CDSS is symptom based, and the telephone nurses enter the CDSS using as a search term the main symptom presented by the caller. Despite use of a CDSS to increase patient safety, medical errors do occur within telephone nursing, (11) and these errors are reported as malpractice claims (1). In Sweden, it is mandatory for healthcare providers to report risk of medical errors and events that have led to or could have led to a medical error to the responsible authority (2). A medical error can be defined as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”(12). The new Patient Safety Law from 2011(2) placed the responsibility for investigating the medical error and taking the measures needed to prevent/protect patients from further medical errors on the healthcare provider. The law was later revised (3) by prescribing the measures healthcare providers should take when an event resulted or could have resulted in severe medical error for the patient involved. It also stressed the importance of learning from medical errors; knowledge transfer is reported to be of the utmost importance to successful patient safety work. When the preceding law was in force (13), it was the responsibility of the Swedish Board of Health and Welfare to conduct an investigation (root cause analysis) to identify what went wrong, and why, when a patient was affected by a medical error. In a previous study (11), i.e. when the preceding law was in force, we investigated all malpractice claims and healthcare providers’ measures following telephone calls to SHD. In order to describe and understand how the new law (2, 3) has influenced patient safety work within telephone nursing, we collected new data for the period 2011–2018.
In Sweden, the telephone nursing service SHD is organized as a network to which all the regions are connected; each region is responsible for its own call centre. There are 33 call centres across the country. The service is reached through a national telephone number (1177). All SHD sites have the same structure; hence, the telephone nurses work in a call centre without physical contact with care-seekers. The telephone nurses are obliged to use an CDSS developed in-house. This includes medical information on symptoms, guidelines and questions as well as documentation in the patient records. The CDSS used is accessed by entering the main symptom presented by the care-seeker, and problems arise when callers present a range of complex problems (9, 14). Hence, the CDSS constrains the telephone nurses to choosing one main symptom, and nurses tend to pose questions that request confirmation of the absence rather than the presence of symptoms (15). The information and guidelines are assessed by medical expertise regularly to assure high quality and up-to-date information. However, interview studies have shown that telephone nurses do not always use the CDSS as intended, (11, 16, 17) and the image of safety may be compromised.
Telephone nursing is complex; telephone nurses rely on communicative skills to gain the information they need as the basis for their assessments (5, 6, 8). The process of telephone nursing was described by Greenberg as dynamic and goal-oriented, where telephone nurses work in three phases: gathering information, cognitive processing, and output (8). Telephone nurses working within SHD are educated in-house in the Dialogue Process (18), which consists of five phases: open, listen, analyse, motivate and close. However, telephone nurses’ communication with callers seems to be affected by CDSS use, as more closed-ended questions are asked and the dialogue focuses mainly on symptoms, which entails the risk that other relevant aspects will be ignored (15). Such aspects might be pivotal, as Gamst-Jensen et al. (19) showed the importance of exploring callers’ concerns so as to acquire more contextual information and, hence, a richer picture of the situation.
One systematic review suggested that using CDSS to support clinical decisions improves patient care significantly (20). On the other hand, another systematic review (10) revealed that implementation of CDSS does not always have a positive outcome and that use of the tool requires further evaluation. Previous research has shown how telephone nurses correctly estimate the level of urgency in 69% of all contacts and underestimate it in 19% of calls (21). Hansen Holm and Hunsaar (22) presented similar findings, showing that care-seekers in need of acute care were correctly assessed in 82% of cases, and for urgent care, 74% of cases received the correct assessment. Patient safety in telephone nursing can be enhanced by using a CDSS, but other aspects may affect the triage process. The gender of the care-seeker might affect the telephone nurses, (23) and cues of physical dominance (voices with a low fundamental frequency and formant frequencies) have been shown to lead to higher evaluation of medical emergency (24). In addition, limiting the time for each call, to increase accessibility, can result in stress (7) and, thus, negatively affect patient safety. These finding add to the questions surrounding patient safety within telephone nursing. In a previous study, (11) we analysed the characteristics of all malpractice claims arising from calls to SHD during the period 2003–2010 (n = 33). Since the latter study, the number of calls to SHD has increased and, today, SHD is one of Sweden’s largest healthcare providers. For this reason, studies on patient safety work within SHD are of importance.
Malpractice reporting is an important measure in patient safety work. As mentioned, the malpractice reporting system in Sweden is a mandatory no-fault system that differs substantially from the tort litigation systems used in the United States, which compensate patients financially if something goes wrong (25). In Sweden, approximately 1,400 patients die annually and 110,000 patients are affected by a medical error (26). However, Anderson and Abrahamson (27) showed that less than 10 percent of medical errors are reported in Sweden. The healthcare sector in Sweden has become increasingly financially restrained, with consequences for the working environment and high turnover rates among registered nurses (RNs). Simultaneously, technical development has enhanced the telephone system, CDSS and information technology used by telephone nurses. All of these factors have the potential to affect the number of medical errors in telephone nursing either positively or negatively, which is why we wished to conduct this follow-up of our previous study.