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Research Outputs

Work Package 11

Research Topic

Communication at the primary secondary care interface

Lead: NHS Education for Scotland (NES),

Contact: Paul Bowie

Description of work

We will develop European-wide agreement on Standards for the systems-based
management of investigation requests and results handing which can be shared
and implemented for improvement.

Specifically, we will:

  • To identify and disseminate the most up-to-date evidence of the key threats to patient safety associated with systems-management of test investigation requests and subsequent results handling at the interface between primary and secondary care settings.
  • To develop pan-European Consensus Statements on Standards for the management of clinical investigation requests and subsequent results handling in primary care.
  • To develop and pilot test interventions to A. Enhance the reliability of systems to manage investigation requests and results, and B. To develop consensus with EU colleagues on this work taking into account national contexts.


Why the research topic is important

  • Failures in the systems-management of laboratory tests, clinical investigations and results handling in primary care are a significant cause of harm to patients and have been identified by the World Health Organisation as a major risk in health care systems. 
  • We know from the limited research in this area that common systems-based deficiencies include tests results with significant clinical findings going missing or not being returned to the individual who initiated the test, or test results being filed by administrative staff without a clinical decision being made. 
  • Systems for communicating test results and the responsibility for taking action are often poorly understood or implemented. 
  • The consequences and impact of such failures are multi-faceted: for patients this can mean missed or delayed diagnoses and potentially avoidable harm; for the practice team this can mean receiving a formal complaint and also necessitate the requirement to undertake significant event analyses; for individual clinicians this could also mean acomplaint to local health authorities or regulators and the possibility of legal action.


What have we done (our methodology/approach)

  • We will conduct a review of the existing healthcare literature to identify the common communication-related systems failures and harm typologies reported with specific reference to the management of clinical investigation requests and subsequent results handling. A further aim is to uncover interventions that have been implemented in these areas to improve systems management and mitigate risks.
  • Informed by the literature review findings, we will conduct semi-structured/focus group interviews with purposive samples of primary care clinicians and managers based in each NES region to explore common systems-based issues and begin to build consensus on what ‘good systems-based practice’ would look like.  We will also explore with senior clinical leaders outputs from a pilot national safety improvement programme (SIPC) on this topic and incorporate learning. 
  • Informed by human factors principles, we will undertake a business process mapping exercise in a range of general practices with different results handling systems to identify error potential and good practice
  • We will then draft Consensus Statements on Standards and further refine these on an iterative basis using consensus building methods (e.g. educational workshops, modified Delphi groups and a content validity index) with at least 4 mixed groups. 
  • We will then finalise consensus from a Scottish perspective using similar methods with an expert group of 15 GPs who are informed in patient safety and quality improvement. 
  • Next we will identify and recruit relevant clinical and managerial staff groups in each participating European nation in the LINNEAUS collaboration and repeat the consensus building method using at least two rounds of the modified online Delphi process to gain European agreement and consensus.
  • We will also develop, content validate and pilot test relevant interventions to monitor and improve the reliability of practice systems dealing with the management of investigation requests and results (e.g. audit checklist tool).

NHS Education for Scotland have only recently joined the network so some  outputs are not yet available. 

Tools and Guidance notes


Journal papers

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice


Quality and safety issues highlighted by patients in the handling of laboratory test results by general practices-a qualitative study


Measuring system safety for laboratory test ordering and results management in primary care: international pilot study


System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model


The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice



Safety and Improvement in  Primary Care: The Essential Guide 

Edited by: Paul Bowie and Carl de Wet, respectively Programme Director for Safety and Improvement, Department of Postgraduate GP Education, Glasgow, Scotland, UK; General Practitioner, Associate Adviser in Postgraduate GP Education, NHS Education for Scotland (West Region), Glasgow, Scotland, UK

Conference proceedings


LINNEAUS deliverable(s)

Other LINNEAUS reports