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Risk Management in Telepractice (2019)

Telephone Triage Risk Management:   Solutions for Recurrent Error in Ambulatory Care,

Urgent Care and Emergency Department Settings

Course Description.  Can reliable guidelines, supportive technologies, and standards reduce the risk of medical malpractice?    The course examines emerging controversial trends and practices related to access, planned error recovery, new regulations about hospital readmissions and closed circle communications as it relates to informed consent in telephone triage. 21 malpractice case studies illustrate how recurrent errors can be remedied by new technologies and standards. 

Objectives. Upon successful completion of the course, participants will be able to

  • discuss three major trends that influence risk in telephone triage
  • describe professional negligence as it relates to telephone triage
  • describe three key strategies that may help to reduce risk
  • list policies unique to telephone triage
  • analyze 21 case studies

Audience. RNs and NPs (novice and experienced) interested in learning more about the principle, current legal issues related to telephone triage.

Methodology. Participants will read printed course material, analyze case studies, and answer 50 multiple-choice questions.

Faculty. Sheila Wheeler, MSN, RN. Since 1995, Ms.Wheeler has served as an expert witness for plaintiffs and defendants in telephone triage malpractice cases.

Provider. Sheila Wheeler, MSN, RN. has been approved by California Board of Registered Nursing, Provider#10680

Note: The course focuses on malpractice risks specific to telephone triage.  It also provides examples of how improving the components of the telephone triage system—staff, guidelines, standards, training, documentation—can reduce risk. Case studies are analyzed from the perspective of an expert witness (the course instructor), not as a legal expert.

Reviewed by California-based Nurse Manager:

“Right on target, Risk Management in Telepractice educates telephone triage nurses about the risk of malpractice, the importance of excellent communications and clear documentation. Once I started reading, I did not want to put it down.  The case studies were interesting.  Most of the poor outcomes were preventable; in a few it appeared that the nurses either lacked knowledge, education or experience. It takes an experienced nurse with strong documentation skills to work as Advice Nurse. Reading the article made me want to sharpen my skills and encourage others to do the same.”

 Brenda Blain Danner, MSN, RN, CNL, Clinical Nurse Manager, Telephone Care Service 


“We don’t look for patterns of our recurrent mistakes, or devise and refine potential solutions for them. But we could, and that is the ultimate point” (Gawande, 2010)

This course examines recurrent patterns of error (medical malpractice) that contribute to delay in care in telephone triage. It also describes proactive approaches to reduce risk.  Many of the suggestions are based on Joint Commission and Institute of Medicine reports on standards to reduce error and the pioneering work of Avedis Donabedian, M.D. (1992). His model provides a framework for evaluating healthcare quality in categories: “structure” (context), “process” (transactions between patient and provider), and “outcomes” (effects of healthcare on patient health status).  A second influence on this work is a recent article about diagnostic error and risk management (Groszkruger, 2014), who suggests remedies to common problems.

It is the author’s opinion that telephone triage is a form of pre-hospital care which requires clinical expertise to estimate the urgency of presenting symptoms.  Recurrent errors result in failure to assess adequately in order to identify and then classify  potentially urgent symptoms by telephone.  Healthcare Systems often focus on cost-containment to the exclusion of safety. Timely access to care requires a developed culture of safety, sound structure and process for safe outcomes.  Telephone triage systems require quality systems and practice to achieve safety overall.

The 21 case studies used to illustrate legal principles are based on actual events. However, in some cases identifying information  has been omitted.

Standards for Technology

Guideline Design CriteriaIn Clinical Practice Guidelines We Can Trust (2011), the IOM sets forth seven criteria required for appraising guidelines. The IOM recommends that developers set forth design standards for the assumptions, analytic methods, and rationales used in any guideline development. Such design standards would also apply to all telephone triage guidelines. Yet, few guideline developers have provided evidence that their guidelines meet such standards, or allow their proprietaryproductstobetestedandcompared to others. Transparency is lacking in terms of the buyer and the end-user.

Risk of Working in an Information Vacuum   Clinical practice without learning the outcomes of one’s decisions has never been shown to improve practice, whereas specific feedback about outcomes enhances practice safety. AHRQ notes that reliable decision support and feedback systems do not yet exist (2017). Such mechanisms — known as planned error recovery  — allow practitioners access to the final diagnosis for patients evaluated on-site following telephone triage calls. This feature provides for both specific feedback for clinicians and reinforces improved practice.

Technology Can Support Professional Standards.Telephone Triage technology—electronic guidelines and EMR software has the potential to both track standardized triage outcomes as well as to insure planned error recovery. This feature provides mandatory feedback, helping to reduce human error. This essential error reduction strategy promotes a method to self-check or double-checks another person’s work (The Joint Commission).Integrating planned error recovery enables nurses to learn from their mistakes and successes, thereby reducing system error.


·      Agency for healthcare research and quality (AHRQ) (2018).  Diagnostic errors. Patient safety network,   US Dept. of Health and Human Services

·      Ambady, N., et al. (2002). Surgeons’ tone of voice: a clue to malpractice history. Surgery; 132(1):5-9.

·       Budryk, Z. (2016) Malpractice claims against nurses on the rise. Jan 26,

  • Carroll, A.E. (2015). To be sued less, doctors should consider talking to patients more. The new health care, June 1, New York Times, New York, NY.
  • Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program (HRRP) (2018)
  • Clawson, J. & Dernocoeur, K. B. (2014). Principles of Emergency Medical Dispatch. National/International Academy of Emergency Medical Dispatch, Salt Lake City, Utah.
  • Donabedian A. (1992). Quality assurance. Structure, process and outcome. Nursing Standard. Royal College Of Nursing. Great Britain). 1992; 7(11 Suppl).
  • Emergency Nurses Association (2015) Position Statement: Telephone Triage
  • Gawande, A. (2010). The checklist manifesto. Picador, NYC.
  • Giesen P, Ferwerda R, Tijssen, et al. (2007). Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency? Quality and Safety in Health Care.16:181–4.
  • Gladwell, M. (2005). Blink: the power of thinking without thinking. Little, Brown & Co., NY.
  • Greatbatch, D. et al. (2005) Telephone triage expert systems and clinical expertise. Sociology of Health & Illness. 27(6):802-30.
  • Groszkruger, D. (2014). Diagnostic error: untapped potential for improving patient safety? Journal of Health care Risk Management, Vol 34, No 1, P 38-41
  • Hargestam, M. et al. (2009) Communication in interdisciplinary teams: exploring closed-loop communication during in situ trauma team training.
  • Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press.
  • IOM(2011). Clinical Practice Guidelines We Can Trust, March

  • Lephrohon, J & Patel, V. (1995). Decision Strategies in Emergency Telephone Triage. Medical Decision-making, 15 (3): 240-253.

·       Mahlmeister, Laura PhD, RN; Van Mullem, Chris MS(c), RN (2000). The Process of Triage in Prenatal Settings: Clinical and Legal Issues. The Journal of Perinatal & Neonatal Nursing: March – Volume 13 – Issue 4 – p 13–30.

  • Perrin, EC.,Goodman, HC. (1978) Telephone Management of Acute Pediatric Illness.j New England Journal of Medicine. 298:130-135.
  • Poole, S.R. (2003). The Complete Guide to Developing Telephone Triage and Advice for a Pediatric Office Practice During Office Hours and/or After Hours. American Academy of Pediatrics, Elk Grove Village, IL.
  • Reason J. (2000). Human Error: Models and management. BMJ. Mar 18; 320(7237):768-770.
  • Reisman AB, Brown K. E. (2005). Preventing communication errors in telephone medicine: A case based approach. Journal of general internal medicine. Oct;20:959-63.
  • Reising, D. L. Allen, P. N. (2007). Protecting yourself from malpractice claims. 2 Num. 2 February
  • Sax, D. et al. (2018). Tele-Triage Outcomes For Patients With Chest Pain: Comparing Physicians And Registered Nurses, Health Affairs December, 37: 12
  • Segen’s Medical Dictionary. © 2012 Farlex, Inc.
  • Smith, R. (2005). Telephone Triage Risk Management, TeleTriage Systems Continuing Education Course,
  • The Joint Commission. (2015). Human Factors Analysis in Patient Safety Systems, The Source, April, Volume 13, Issue 4.
  • URAC  (2019).  Telehealth  Nursing  and  Medical  Call  Center  Standards.  Health  Call  CenterAccreditation  Standards  Summary, URAC
  • Wachter, R, (2015). The Digital Doctor, Hope, Hype and Harm at the Dawn of Medicine’s cumputer Age. McGraw Hill, NY NY.
  • Wetterneck TB, Karsh BT (2011): Human factors applications to understanding and using close calls to improve health care. In Wu A, editor: The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm. Oak Brook, IL: The Joint Commission Resources, 2011, 39–53.
  • Wheeler, S. Q, Windt, J. (1993). Telephone Triage: Theory, Practice and Protocol Development. TeleTriage Publishers, San Anselmo, CA.
  • Wheeler et al. (2015). Safety of Clinical and Non-Clinical Decision Makers in Telephone Triage: A Narrative Review, Journal of Telemedicine and Telecare.
  • Wheeler, S.Q. (1995-2018). Telephone Triage Guidelines for Adult Populations. TeleTriage Systems Publishers, San Anselmo, CA




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  1. Order the article and Post Test online through PayPal.

    • You will receive links to the course materials and Post Test via email.
    • You will receive articles via email,  OR, if appropriate a Book (downloadable or hard copy)  included in the price of this course
    • Read the required reading material.Complete the post test and submit it via emai
  2. If you pass with 70%, you will receive a Certificate of Completion via email within 1-5 business days

6 CE Hours for $90


Do not order online from your work site email address, your order may be delayed or lost.

Place your order from your personal email.

Always check your spam filter for delivery of the CE course