Errors in nurse-led triage: An observational study

Ausserhofer, Dietmar; Zaboli, Arian; Pfeifer, Norbert; Solazzo, Pasquale; Magnarelli, Gabriele; Marsoner, Tania; Siller, Marianne; Turcato, Gianni

doi:10.1016/j.ijnurstu.2020.103788

Cited by 30 publications

(34 citation statements)

References 21 publications

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“…Usually, triage decisions are made by nurses and trained specialists, whose workload is generally high [ 5 ]. Increased workload and overcrowding pose huge risks as triage errors currently occur in roughly 16% of all cases [ 6 ] and nurses often rely on their intuition and speed up triage by not collecting further information, for example, medical history and physiological data [ 7 , 8 ]. These risks and the workload for health care workers could be reduced if patients were guided to appropriate health care facilities before visiting an ED to receive an initial assessment.…”

Section: Introductionmentioning

confidence: 99%

The Triage Capability of Laypersons: Retrospective Exploratory Analysis

Kopka¹,

Feufel²,

Balzer³

et al. 2022

JMIR Form Res

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Background Although medical decision-making may be thought of as a task involving health professionals, many decisions, including critical health–related decisions are made by laypersons alone. Specifically, as the first step to most care episodes, it is the patient who determines whether and where to seek health care (triage). Overcautious self-assessments (ie, overtriaging) may lead to overutilization of health care facilities and overcrowded emergency departments, whereas imprudent decisions (ie, undertriaging) constitute a risk to the patient’s health. Recently, patient-facing decision support systems, commonly known as symptom checkers, have been developed to assist laypersons in these decisions. Objective The purpose of this study is to identify factors influencing laypersons’ ability to self-triage and their risk averseness in self-triage decisions. Methods We analyzed publicly available data on 91 laypersons appraising 45 short fictitious patient descriptions (case vignettes; N=4095 appraisals). Using signal detection theory and descriptive and inferential statistics, we explored whether the type of medical decision laypersons face, their confidence in their decision, and sociodemographic factors influence their triage accuracy and the type of errors they make. We distinguished between 2 decisions: whether emergency care was required (decision 1) and whether self-care was sufficient (decision 2). Results The accuracy of detecting emergencies (decision 1) was higher (mean 82.2%, SD 5.9%) than that of deciding whether any type of medical care is required (decision 2, mean 75.9%, SD 5.25%; t>90=8.4; P<.001; Cohen d=0.9). Sensitivity for decision 1 was lower (mean 67.5%, SD 16.4%) than its specificity (mean 89.6%, SD 8.6%) whereas sensitivity for decision 2 was higher (mean 90.5%, SD 8.3%) than its specificity (mean 46.7%, SD 15.95%). Female participants were more risk averse and overtriaged more often than male participants, but age and level of education showed no association with participants’ risk averseness. Participants’ triage accuracy was higher when they were certain about their appraisal (2114/3381, 62.5%) than when being uncertain (378/714, 52.9%). However, most errors occurred when participants were certain of their decision (1267/1603, 79%). Participants were more commonly certain of their overtriage errors (mean 80.9%, SD 23.8%) than their undertriage errors (mean 72.5%, SD 30.9%; t>89=3.7; P<.001; d=0.39). Conclusions Our study suggests that laypersons are overcautious in deciding whether they require medical care at all, but they miss identifying a considerable portion of emergencies. Our results further indicate that women are more risk averse than men in both types of decisions. Layperson participants made most triage errors when they were certain of their own appraisal. Thus, they might not follow or even seek advice (eg, from symptom checkers) in most instances where advice would be useful.

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Section: Introductionmentioning

confidence: 99%

The Triage Capability of Laypersons: Retrospective Exploratory Analysis

Kopka¹,

Feufel²,

Balzer³

et al. 2022

JMIR Form Res

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“…Mistriaged adult patients have significantly longer ED stays than those correctly triaged. 31 Our work builds on previous literature exploring triggers to improve patient safety in the ED and, specifically, advance medical error detection methods. The PPV of 48% for under-triage compares favorably to other ED-based triggers.…”

Section: Discussionmentioning

confidence: 99%

Under-triage: A New Trigger to Drive Quality Improvement in the Emergency Department

Berkowitz

Morrison

Shaukat

et al. 2022

Pediatric Quality &Amp; Safety

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Introduction: The emergency department (ED) is a care setting with a high risk for medical error. In collaboration with our nursing colleagues, we identified a new trigger, under-triage, and demonstrated how its implementation could detect and reduce medical errors in the ED. Methods: We defined under-triage as patient visits with an Emergency Severity Index (ESI) score of 4 or 5 (ie, low acuity), and the patient was admitted to the hospital during the same visit. We defined mistriage, or medical error, when nurse-physician dyad reviewers determined that a different ESI level should have been assigned based on the information available at triage. A multidisciplinary team used nominal group technique to build consensus on key drivers and outcome metrics for this new trigger. We randomly selected 267 charts for review utilizing the under-triage trigger. Results: Of the 125,457 patients triaged as level 4 or 5 in 2019 and 2020, 1.1% (n = 1,423) were under-triaged. Of the 267 charts reviewed, 127 were categorized as mistriage, making the under-triage’s positive predictive value trigger 48%. Reviews took 2–10 minutes per chart. We identified 10 categories of under-triage. Nine themes emerged, with four specific and measurable action items mapped to process and outcome metrics. Conclusions: We identify a new, feasible ED trigger, under-triage, that identifies medical error with a high positive predictive value. We identify process and outcome metrics and interventions to improve triage for future patients.

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“…While the TEWS does affect the allocation of the final triage score, one error may not necessarily result in a triage priority error. Triage scores are directly impacted by discriminators, and discriminator errors occur frequently in triage, most often in relation to pain [17] , [18] , [19] , [20] , [21] . Pain is scored according to the numeric pain rating scale with numbers 0 to 3 indicating mild pain, 4 to 6 indicating moderate pain and 7 to10 indicating severe pain.…”

Section: Discussionmentioning

confidence: 99%