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Repeated Calls to Emergency Out of Hours Medical Services 

In this report, the Norwegian Healthcare Investigation Board (Ukom) focuses on emergency out of hour medical services. We have examined how calls for help are handled when individuals contact the out of hours emergency services for assistance. 

The study is based on the case of "Ida," who was heavily pregnant and died from pneumonia during one of the last waves of the coronavirus pandemic. Ida contacted the health services several times. Her condition was assessed by a substitute general practitioner, two different telephone operators at the out of hours emergency services, a resource coordinator at the Emergency Medical Communication Central (AMK), and two emergency doctors over the phone. 

As of January 2024, Ukom has received over 300 reports of serious adverse events at emergency services. A common denominator for several of these reports is that the severity of the situation was not recognized, and that patients or relatives contacted the emergency services multiple times during an illness. 

In conducting the study, we interviewed Ida`s mother, health personnel and leaders, read patient records, and conclusions from the County Governor. We also listened to audio logs from the Emergency Medical Communication Centre and the emergency service center. The Systems Engineering Initiative for Patient Safety (SEIPS) was used as a theoretical framework. In the analysis, we used AcciMap and "patient safety challenge analysis form" based on the methodology of the Norwegian Accident Investigation Board. 

Based on our study, we particularly point out six themes that together can have implications for patient safety when patients call the emergency services. 

Good communication skills are important in all clinical situations. Ukom finds that the health service in general does not pay enough attention to clinical communication as a skill. The risk of this becomes particularly evident in situations where communication occurs over the phone. Healthcare professionals need adequate training in gathering information in a suitable and systematic manner tailored to the individual patient. 

The concept of "make contact again if the condition worsens" is unclear. It is a concept that has been established at the emergency services among both doctors and nurses, but it can be difficult to explain in practice. Recontact is not always captured. 

The health professional competence, communication skills, and practical experience of telephone operators have an impact on decisions made under time pressure. Insufficient training or assurance of competence can lead to failing assessments. The basis for decision-making is influenced by factors such as: decision support tools and their use, access to information, video service, and other technological systems at the emergency services. 

Doctors do not always receive the follow-up and training necessary to perform work at the emergency services in a safe manner. 

It is challenging to maintain responsibility for leadership and quality improvement at an emergency service. Factors such as a wide leadership span, high turnover among leaders, and varying degrees of interaction with municipal management can have an impact on this. Mapping of risk areas and internal review after serious adverse events with a view to learning are carried out to a limited extent. 

The recommendations in the report are related to competence requirements in clinical communication, notification of recontact, use of video, audio recordings for doctors, decision support tools, need for clarification of concepts, standardization, and making advice available. 

The report is relevant for the Ministry of Health and Care Services, the Directorate of Health, supervisory authorities, politicians, leaders in the municipality at various levels, leaders and employees in the emergency medical chain, professional environments, patients, and relatives. 

The translation from Norwegian to English is based in AI. Ukom has reviewed, edited and quality assured the translation.