111 Referral Standard: Clinical Safety Case Report

The 111 information standard hazard log is embedded below

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.

Hazard Number	Hazard Name	Hazard Description	Hazard Causes	EFFECT - Patient Safety Impact Description	Initial Risk - Likelihood	Initial Risk - Consequence	Initial Risk - Acceptability	Dependencies and Assumptions	Existing Controls / Mitigations	Residual Risk - Likelihood	Residual Risk - Consequence	Residual Risk - Acceptability	Summary of Actions	Additional Comments
1	Missing data (blank fields) , Incorrect, corrupt data	Data items left blank or corrupted in transmission.	Incorrect data entry, mapping errors, or system failure.	Inappropriate care, delay to care, or patient harm.	Medium	Considerable	3	Standardized implementation by suppliers.	Assurance processes in place.	Low	Considerable	2	Implementation guidance to explain conformance.	Hazard transferred to suppliers.
2	Incorrect mapping / transcription	Suppliers map incorrect codes or data.	Recommended coding not available in system.	Incorrect treatment or advice given by clinician.	Medium	Considerable	3	HL7/FHIR implementation by suppliers.	Standardized data dictionary.	Medium	Significant	2	Guidance on reference sets and messaging.	Hazard transferred to suppliers.
3	Unstructured data not easily accessible	Data exists in free text form (unstructured).	Supplier ability to send/render free text.	Information may be missed leading to delays in care.	Medium	Minor	2	System can handle/render free text.	Standard ITK messaging used.	Low	Minor	1	Default to data sets; use free text as backup.	Hazard transferred to suppliers.
4	Existing info (meds/allergies) not included	111 standard only captures 'new' info.	Presumption that SCR/GP Connect is available.	Clinician unaware of existing meds/allergies.	Medium	Major	3	Access to SCR/Shared care records.	Access to SCR is common.	Low	Major	2	Include warning boxes about 'new' info only.	Hazard transferred to suppliers.
5	Unconfirmed diagnoses recorded as problem	Diagnoses with 'suspected' qualifier recorded as confirmed.	GP systems unable to recognize qualifiers.	Incorrect updates to patient records.	Medium	Significant	2	Suppliers can disable suspected qualifiers.	Manual coding from ITK messages.	Low	Significant	2	Explain mapping of chief clinical concern.	Hazard transferred to suppliers.
6	Disclosure of Gender reassignment	Sharing sex and gender where they don't match.	Breach of GDPR Article 9.	Psychological impact on individual.	Medium	Considerable	4	Patient consent gained for recording.	Both fields are 'required', not 'mandatory'.	Low	Considerable	2	Explain impact and prompt for consent.	Hazard transferred to suppliers/orgs.
7	Individuals not matched on SPINE	Patients not registered with a GP cannot be matched.	111 uses GP registered on SPINE for referrals.	Referral to GP cannot be sent.	Medium	Minor	2	Existing processes for unregistered patients.	Handler advises patient to register.	Medium	Minor	2	N/A	Hazard transferred to health org.
8	Incorrect entry of diagnosis code	SNOMED qualifiers (e.g. Suspected) not ingested.	GP systems unable to display qualifiers.	Incorrect diagnosis appears in reports.	High	Significant	3	Suppliers working on solutions for qualifiers.	Pathways does not yet use SNOMED.	Low	Significant	2	Review when Pathways introduces SNOMED.	Hazard transferred to NHS E&I.

This Hazard log will need to be reviewed when Pathways introduced Snomed CT and the 111 referral standard is impacted.

Full testing will need to be performed by suppliers when pathways moves to Snomed

Hazard transferred to NHS E&I With regards to wider management of development of sending and receiving of structured data and SNOMED coded data.

In the short term GP Suppliers to ensure qualifiers are shared and surfaced in sstems appropriately.

Please note: The mitigations we have taken to address clinical safety risks are largely in relation to the transmission of data between software suppliers systems. Further mitigations will be required when the headings are implemented in electronic health record systems. We have flagged some risks relating to implementation in this report, but expect that further mitigations will be identified as clinical risk assessments and safety cases are developed by vendors and sites during the implementation.