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J Telemed Telecare. 2015 Sep;21(6):305-22. doi: 10.1177/1357633X15571650. Epub 2015 Mar 10.

Safety of clinical and non-clinical decision makers in telephone triage: a narrative review.

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Assistant Clinical Professor Northern Arizona University 3895 N. Business Center Dr. Ste 120 Tucson, Arizona 85705, USA
President, Mahlmeister and Associates Clinical Professor University of California San Francisco San Francisco, California 1567 Winding Way Belmont, California 94002, USA.
Assistant Adjunct Professor, University of California San Francisco.
Department of Social and Behavioral Sciences 3333 California St, Suite 455 San Francisco, CA 94118, USA.


Patient safety is a persistent problem in telephone triage research; however, studies have not differentiated between clinicians' and non-clinicians' respective safety. Currently, four groups of decision makers perform aspects of telephone triage: clinicians (physicians, nurses), and non-clinicians (emergency medical dispatchers (EMD) and clerical staff). Using studies published between 2002-2012, we applied Donabedian's structure-process-outcome model to examine groups' systems for evidence of system completeness (a minimum measure of structure and quality). We defined system completeness as the presence of a decision maker and four additional components: guidelines, documentation, training, and standards. Defining safety as appropriate referrals (AR) - (right time, right place with the right person), we measured each groups' corresponding AR rate percentages (outcomes). We analyzed each group's respective decision-making process as a safe match to the telephone triage task, based on each group's system structure completeness, process and AR rates (outcome). Studies uniformly noted system component presence: nurses (2-4), physicians (1), EMDs (2), clerical staff (1). Nurses had the highest average appropriate referral (AR) rates (91%), physicians' AR (82% average). Clerical staff had no system and did not perform telephone triage by standard definitions; EMDs may represent the use of the wrong system. Telephone triage appears least safe after hours when decision makers with the least complete systems (physicians, clerical staff) typically manage calls. At minimum, telephone triage decision makers should be clinicians; however, clinicians' safety calls for improvement. With improved training, standards and CDSS quality, the 24/7 clinical call center has potential to represent the national standard.


clinical; decision; non-clinical; safety; telephone triage

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