Patient safety in after-hours telephone medicine.

Telephone medicine is common. Radecki and colleagues estimated that telephone medicine accounts for up to 25% of patient encounters, one fifth of which occur after hours. Taking the number of 2004 outpatient visits in the United States (roughly 9.9 billion), and multiplying by .05 (25% x 20% from above), this could mean there are more than 49 million after-hours telephone medicine encounters per year in the United States. The research reported in this paper examined the practice of telephone medicine to find and characterize threats to patient safety. Threats to patient safety were suspected for several reasons. Telephone medicine removes visual cues. Clinicians use cues in the office setting, such as general appearance of patients, to decide which patients may be sicker than others. Further, studies of telephone “triage” show discrepancies between diagnoses made over the phone versus in person. Finally, after-hours telephone medicine may be conducted when the doctor is sleepy or distracted and is often without access to patient records. The potential for harm to patients appears to be high. The results of Medline searches for papers on telephone medicine can be broken down into several categories: triage studies, systems studies, and outcomes studies. Triage studies include many randomized, controlled trials showing that triage over the phone frequently misses significant illness. Systems studies, such as Hildebrandt’s study of an after-hours telephone service in primary care, show that there can be simple and serious flaws in telephone systems that result in poor patient care. Studies about patient outcomes (rather than economic outcomes studies) can be broken down into three groups—compliance with nurse/physician recommendations, diagnoses made in the emergency room after referral, or patient-centered outcomes studies that look at what happened to all the patients who called. Currently, there are no studies in the literature analyzing the potential for harm to patients in the content of after-hours phone calls between doctors and patients.