Article Text

Errors in after-hours phone consultations: a simulation study
  1. Erel Joffe1,2,
  2. James P Turley1,
  3. Kevin O Hwang3,
  4. Todd R Johnson1,
  5. Craig W Johnson1,
  6. Elmer V Bernstam1,3
  1. 1School of Biomedical Informatics, The University of Texas Health Science Center, Houston, Texas, USA
  2. 2Department of Hematology and Bone Marrow Transplantation, Tel Aviv Medical Center, Tel Aviv, Israel
  3. 3Department of Internal Medicine, Medical School, The University of Texas Health Science Center, Houston, Texas, USA
  1. Correspondence to Dr Elmer Bernstam, School of Biomedical Informatics, The University of Texas Health Science Center, 7000 Fannin, Suite 600 Houston, TX 77030, USA; Elmer.V.Bernstam{at}


Background After-hours out-of-hospital phone consultations require physicians to make decisions based on information provided by a nurse over the phone.

Methods We conducted a simulation study to evaluate physicians’ actions following communication of key information. 22 nurses were asked to call physicians with six cases based on the six most common reasons for after-hours phone calls. We evaluated physicians’ actions following the communication of key clinical information: A situation cue described a patient's problem (eg, confusion). A background cue described a specific clinical finding regarding the cause of the problem (eg, patient's sodium is low). For each cue we defined a list of indicators, based on the medical literature, to ascertain whether physicians acted upon the provided information (which was defined as addressing at least one of the indicators).

Results A total of 108 phone consultations (containing 88 situation and 93 background cues) were analysed. Situation cues were communicated in 90% (79/88) of the calls and background cues in 33% (31/93). Physician acted upon the provided information in 57% (45/79) and 48% (15/31) of the communicated situation and background cues, respectively. When the background cues were not communicated, physicians asked questions expected to elicit the cue in 12% of the cases. Responding to the situation cue was associated with longer conversations and active inquiry by the physician.

Conclusions After-hours phone calls are error prone. Both nurse communication and physician decision-making are problematic. Efforts to improve patient safety in this setting must address both communication and decision-making.

  • Communication
  • Diagnostic Errors
  • Hand-Off
  • Hospital Medicine
  • Human Error

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