A systematic review and ‘best-fit’ framework synthesis of contributory factors to telephone triage safety

• Appropriateness is the most common indicator of telephone triage safety. • Research using data from actual patient safety incidents is limited. • Individual worker and patient factors contributory factors were most common. • Physical environmental contributory factors are not well investigated. • A new definition of telephone triage safety is proposed including all indicators. Telephone triage is a popular service globally but is under-represented in healthcare safety research and the definition of its safety is not well understood. Moreover, human factors frameworks for organisational learning are often designed for use in face-to-face healthcare and may be less reliable for detecting contributing factors in telemedicine. A systematic review of peer-reviewed literature in Scopus and PubMed databases to identify patient safety indicators and contributing factors to primary care telephone triage safety was conducted. Both qualitative and quantitative studies were included. No studies were excluded due to quality but Critical Appraisal Skills Programme tools supported commentary on quality considerations. 96 peer-reviewed articles met the requirements for inclusion, and definitions of, and contributing factors to safety were synthesised using the Systems Engineering Initiative for Patient Safety (SEIPS) as a ‘best-fit’ framework. Few studies defined safety. Most included studies measured ‘appropriateness’ of care/advice. Few research articles used data from actual incidents and/or near-misses. To reflect the various safety indicators “actionable, appropriate, and timely care, avoiding unavoidable deterioration or harm” is proposed as a working definition for telephone triage safety. Regarding contributing factors to telephone triage safety, most studies focused on individual worker and patient factors. Physical environment and organizational factors were under-researched, which is particularly pertinent since both are likely to differ from face-to-face care, unveiling noteworthy directions for future research. The review culminated in a list of contributory factors to patient safety in telephone triage with potential to use these to support incident investigation and system redesign.