111 Referral Standard: Clinical Safety Case Report
Clinical Risk Control
Of the 8 hazards originally identified, 1 was scored at level 4, 5 at level 3 and 2 at level 2 all of which required additional controls to reduce risk to an acceptable level. After the additional controls and mitigations were evaluated and verified during the hazard workshops the residual hazards are:
- 6 hazards were reduced to level 2 - Acceptable where cost of further reduction outweighs benefits gained.
- The remaining 2 hazards 1 remained at level 2 and the other reduced to level 1 - acceptable, no further action is required.
There are 6 hazards with a residual risk of 2, which is Undesirable level of risk, attempts should be made to eliminate or control to reduce risk to an acceptable level.
Below is a summary of each of the hazards that were initially give a risk raking of 3 and above.
| Hazard Id: | 1 |
|---|---|
| Initial risk ranking | 3 |
| Hazard Name | Missing data (blank fields), incorrect, or corrupt data. |
| Hazard Description: | Data items that are either not completed, completed incorrectly, or corrupted in message transmission which result in blank fields in the sending and /or receiving system. |
| Hazard Causes: | 1) Incorrect data entered in source system unable to be mapped into the receiving system. 2) Information model in source system is misinterpreted/not understood by? 3) Logical data model is wrong leading to incorrect or missing data attributes. 4) Data processing and de-duplication loses important data item. 5) Headings have similar meanings, so users are unsure where to find the information they need e.g. About Me, Individual Requirements and Social Context. 6) Consequence of different professional groups with different roles and emphasis in creating electronic health and care records. 7) Semantics and language difference between the different professions. |
| Potential patient safety impact description | Healthcare provider delivers inappropriate care based on absent / incorrect information which could lead to an absence or delay to care, which could result in patient harm. |
| Dependencies & assumptions | 1. Suppliers implement the standard in accordance with the PRSB guidance provided. 2. Supplier systems are able to configure their system to support recommended conformance. |
| Mitigation: | Existing controls / Mitigation Assurance/compliance processes already published for system suppliers / implementers. Design Mitigations Providing system suppliers with implementation guidance explaining confirmation on data item conformance - 'Mandatory (& Must haves), Required and optional Data standard has been designed to ensure conformance criteria is clear as described on page 6 of the General implementation guidance for ALL PRSB standards [Ref 7] |
| Residual risk: | 2 |
| Hazard Id: | 2 |
| Initial risk ranking | 3 |
| Hazard Name | Incorrect mapping / transcription of data items from source systems (including paper/excel) into receiving system. |
| Hazard Description: | Suppliers map incorrect codes or data. Incorrect transcription of written terminology |
| Hazard Causes: | 1) Recommended coding not available in supplier system. |
| Potential patient safety impact description | Incorrect treatment or advice given by the HCP which could lead to an absence or delay to care, which could result in patient harm. |
| Dependencies & assumptions | 1. Supplier systems can implement the 111-standard using the recommended coding via HL7 and/or FiHR for input and extract. |
| Mitigation: | Existing controls / mitigations Assurance / compliance processes already in place for system suppliers / implementers. Design mitigations The information standard has been developed with specific headings which link to SNOMED codes, NHS Data Dictionary, Reference sets where appropriate, including conformance and compliance requirements |
| Residual risk: | 2 |
| Hazard Id: | 4 |
| Initial risk ranking | 3 |
| Hazard Name | Known, existing information e.g. medications and allergies may not be available to receiving service |
| Hazard Description: | The 111 standard captures and passes to receivers 'new' information only. There is a presumption that existing / known information e.g. medications, allergies, risks will be available via Summary Care Record, GP Connect, shared care records etc. |
| Hazard Causes: | 1) Medication, allergies and risk Information captured in the 111 standard is 'New' patient reported information only. 2) Not all services have access to Summary Care Record so are unable to view existing GP information 3) shared care records are not available to all health and care settings, |
| Potential patient safety impact description | Information already recorded in existing clinical systems is not shared as part of the 111 standard. Not being aware of this information may result in inappropriate advice or care being given to the patient resulting in harm to the patient |
| Dependencies & assumptions | 1. Majority of services have access to existing health and care records 2. The NHS E road map for access to Health & care records includes dentistry, ophthalmology and pharmacy etc. |
| Mitigation: | Existing controls / implementers Many services are able to access a person's core information (medications, allergies and adverse reactions) via the SCR) Most of the time the individual or advocate will be able to provide the information via memory or patient access to GP records.. Design mitigation The standard includes a field for the 111 call handler / CAS clinician to include a link to where other information about the patient can be accessed (Local shared care record) Clinical suppliers should consider including a warning that the 'medication, allergies and adverse reactions and risks in the 111 referral are patient reported only' |
| Residual risk: | 2 |
| Hazard Id: | 5 |
| Initial risk ranking | 3 |
| Hazard Name | Unconfirmed diagnoses recorded into GP record as a problem |
| Hazard Description: | The 111 standard allows for the recording of presenting complaint, chief complaint, chief clinical concern and diagnoses. Care must be taken when recording diagnoses with a qualifier e.g. suspected as GP systems do not always recognise the qualifier. |
| Hazard Causes: | 1) GP systems cannot easily record a diagnosis with a qualifier and may incorrectly add a diagnosis code to the patient record |
| Potential patient safety impact description | Patient's records will be incorrectly updated and may cause issues for the patient with regards to contraindicated care/medicines and obtaining a mortgage / life insurance |
| Dependencies & assumptions | 1. Suppliers can disable the recording of diagnoses with a 'suspected' qualifier 2. Suppliers can capture the Chief clinical concern using SNOMED findings data set (suspected diagnosis) |
| Mitigation: | Existing controls/mitigations Systems receiving ITK messaging can manually code information into the care record from the 111 / discharge report and search for suspected diagnoses code. Design mitigation Systems should map Chief clinical concern to SNOMED findings (suspected diagnosis) and Diagnoses to diagnoses codes that do not require a qualifier. |
| Residual risk: | 2 |
| Hazard Id: | 6 |
| Initial risk ranking | 4 |
| Hazard Name | Disclosure of Gender reassignment without the individual’s consent/knowledge |
| Hazard Description: | Sharing both 'sex' and 'gender' where the gender does not match the ‘sex’ phenotype recorded at birth for example within a referral letter, discharge summary or electronic shared care record, (without the individual’s consent) could lead to inappropriate sharing of sensitive personal data. (In breach of GDPR Article 9) |
| Hazard Causes: | The two data items 'Sex' and 'gender' recorded as part of the 111 Standard, where they do not match, could indicated gender reassignment. Disclosure of a person's gender reassignment without the consent of the individual is prohibited under GDPR Article 9 |
| Potential patient safety impact description | Disclosure of a person’s gender reassignment without their consent could impact the individual psychologically and may lead to harm of the individual |
| Dependencies & assumptions | Conversation will be had with individuals about the recording of 'sex' and 'gender' either to gain their consent or to agree not to record specific information.
|
| Hazard Id: | 8 |
| Initial risk ranking | 2 |
| Hazard Name | Incorrect entry of diagnosis code in the persons GP electronic record |
| Hazard Description: | The SNOMED Ref set is a very large ref set which includes diagnosis codes with qualifiers i.e. . If a clinician was to select UTI with a qualifier of 'Suspected' . The UTI would be recorded in the patient record but the qualifier would not. Resulting in an unconfirmed diagnosis being added to the record |
| Hazard Causes: | GP systems unable to ingest and display 'qualifiers' linked to diagnosis SNOMED codes in the GP electronic record. Use of the SNOMED ref Set for Chief Clinical Concern may cause incorrect coding of diagnoses |
| Potential patient safety impact description | The incorrect diagnosis will appear in any reports requiring their diagnosis to be extracted from the clinical record. Patient may not be prescribed a medication due to possible contraindications with a diagnosis in their record. |
| Dependencies & assumptions | 1. Primary care clinical system suppliers are working on a solution for displaying the 'qualifiers' attached to a diagnosis SNOMED code 2. The SNOMED ref set will be available to the clinician to select from in the 111 Standard for referrals and PEM for information |
| Mitigation: | **Existing controls / mitigations Pathways does not yet use Snomed CT therefore the Ref set is not yet available to the clinician to select a diagnosis with a qualifier. **Design mitigation The clinician can enter free text which will be transferred as part of the 111 Standard. The pathways SG and SD codes will be pulled through from Pathways.. **Technical Assurance To be confirmed as part of supplier testing |
| Residual risk: | 2 |
Page last updated: 06 January 2026