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Table 1 Diagnostic error prevention strategies

From: Strategies to reduce diagnostic errors: a systematic review

No Author, year and country Aim Intervention delivery mode and strategy type Design and sample size Intervention Control Setting Targeted Clinicians Conclusion
  Communication Strategies
1 Cannon et al., [54], 2000, US To evaluate the effectiveness of computerised reminder system for mood disorder screening Computerised trigger system via a communication strategy RCT Total sample size =78 Intervention =41 Control =37 Computer program generated reminders to screen the patients for mood disorders. Program scored the mood disorder based on 4th edition of Diagnostic and Statistical Manual of Mental Disorders using answers given to questions patients’ progress notes were generated Used a paper checklist inserted in the paper medical record Psychiatric (outpatient) Psychologists, registered nurses, social workers, therapists Computer reminders shown to be superior to manual reminders in improving adherence to clinical practice guideline
2 Meyer et al., [56] 2016, US To find effective communication strategies to inform primary care providers about the delayed follow-up Computerised trigger system via a communication strategy RCT Total sample size = 733 Control = 364 Intervention = 369 Communication through three escalating steps: 1st emails 2nd 3 phone calls 3rd inform clinical director Usual communication process without any follow-up steps Cancer Physicians, physician assistants, nurse practitioners Communication strategy to primary care providers on delayed follow-up of findings suspicious of cancer were useful, but not fail-safe. Need for additional back-up strategies - using case coordinators
3 Singh et al., [58] 2007, US To examine the effectiveness of computerised notification system for diagnostic test results Computerised trigger system via a communication strategy Non-randomised descriptive study Total sample size = 1017 Weekly computerised tracking system to identify alerts of abnormal imaging reports Laboratory Health care providers, diagnostic-investigation providers Computerised test result notification system alerted physicians of abnormal results through electronic medical record but imaging results continue to be lost to follow-up. Rate of results lost to follow-up lower than that reported in systems that do not use information technology
4 Medford-Davis et al., [55] 2015, US To determine presence or absence of diagnostic error, detail of error and associated process breakdown underlying the errors Computerised trigger system via a communication strategy Non-randomised retrospective descriptive study Total sample size =100 An electronic “trigger” algorithm identified patients at high risk of diagnostic errors to facilitate selective record review ED ED clinicians For patients in ED with abdominal pain, diagnostic process breakdown commonly involved history-taking, ordering insufficient tests in the patient provider encounter and problems with follow-up of abnormal test results
5 Murphy et al., [57] 2015, US To determine if electronic patient record trigger system identifies patients at risk Computerised trigger system via a communication strategy RCT Total sample size = 72 Intervention = 36 Control = 36 Electronic triggers applied twice to electronic health record data repositories to identify records of patients with potential delays in diagnostic evaluation of findings suspicious for cancer Usual follow-up without any electronic trigger activation Cancer Physicians, physician assistants, nurse practitioners Electronic trigger-based intervention effective in reducing time to diagnostic evaluation of cancer. Intervention improved percentage of patients who received follow-up, can be used to improve timeliness of diagnosis of other serious conditions
6 Singh et al., [59] 2010, US To examine whether notification alert system resulted in timely follow-up of abnormal laboratory results Computerised trigger system via a communication strategy Non-randomised prospective descriptive study Total sample size = 1163 Alert tracking system determined whether the alert was acknowledged the provider within two weeks of transmission; acknowledged alerts were considered read. Within 30 days of result transmission, record review and provider contact determined follow-up actions Laboratory Health care providers; diagnostic-investigation providers Automated notification of abnormal lab results did not guarantee timely follow-up on non-life threatening abnormal lab results in the outpatient setting
  Audit Strategies         
7 Aaland et al., [5] 1996, US To develop a policy to perform an ongoing series of patient examination during the entire trauma recovery process by a trauma team Additional patient review via an audit system Non-randomised descriptive study Total sample size = 1873 Patients evaluated in ED (Emergency Department) by trauma team and then discharged were followed within one week of the injury. New injuries identified were recorded and followed up ED (Trauma) General surgeons, ED physicians, medical students Follow up can minimise diagnosis delays by: careful review of initial x-rays; repeating unclear studies; continued serial examination of each patient for entire clinical course; objectively and thoughtfully discussing missed injuries on a routine basis
8 Casalino et al., [36] 2009, US To determine if a patient electronic medical records system reduced error rates Additional patient review via an audit system Non- randomised retrospective descriptive study Total sample size = 5434 A physician survey asked physicians about processes used by them to manage test results Outpatient Primary health care physicians Failures to inform patients or to document informing patients of abnormal outpatient test results are common; use of simple processes for managing results was associated with lower failure rate
9 Perno et al., [44] 2005, US Investigate delayed diagnosis of trauma while specific trauma team in place Additional patient review via an audit system Non-randomised prospective descriptive study Total sample size = 3265 Each paediatric trauma team member had a designated role in the evaluation and care of the trauma patient based on Advanced Trauma Life Support guidelines. After admission, each patient had a daily tertiary examination conducted by a trauma surgery physician starting within 24 h of initial evaluation ED (Trauma) ED paediatricians, ED surgeons, neuro surgeons, paediatric ICU (Intensive Care Unit) fellows, trauma nurses Implementation of an effective paediatric trauma team associated with significant reduction in delay in trauma diagnosis
10 Selker et al., [47] 1998, US To reduce number of cardiac care unit admissions without acute ischemia Computer assistance via an audit system Non-randomised controlled clinical trial Total sample size = 10,698 Intervention = 4738 Control = 5951 Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) automatically printed in patients ECG (Electrocardiogram) Usual diagnosis using ECG without ACI-TIPI printed on ED (Cardiology) ED clinicians ECGs with ACI-TIPI associated with reduced hospitalisation among ED patients without acute cardiac ischemia. ECGs with ACI-TIPI did not affect appropriate admission for unstable angina or acute infarction. Wide use ECGs with ACI-TIPI in the US is likely to lead to fewer unnecessary hospitalisations, especially to coronary care unit
11 Tsai et al., [51] 2003, US To determine the effect of computerised ECG interpretation on non-cardiologists Computer assistance via an audit system RCT Total sample = 1620 Intervention = 810 Control = 810 Internal medicine residents interpreted two equally difficult ECG sets (Set A & B). First, they interpreted ECG set A without the computer interpretation support then interpret ECG set B with computer support. Internal medicine residents interpreted ECG set B without the computer interpretation support first then interpret ECG set A with computer support Laboratory (Cardiology) Non cardiologists internal medicine residents Computer decision support systems can generally improve the interpretive accuracy of internal medicine residents in reading ECGs
12 Bergman et al., [53] 2008, Sweden To determine if novel diagnostic procedures improved diagnostic accuracy and proceeding time in psychiatry Computer assistance via an audit system RCT Total sample size = 63 Implemented a computer assisted diagnostic system to determine processing time and accuracy of diagnosis Used paper and pencil method Psychiatry Clinical psychologists, general practitioners - specialists Specialist-clinical neurophysiology physicians Results showed no major difference in diagnostic outcome between traditional paper and pencil methods and computer support for psychiatric diagnosis
13 Graber et al., [41] 2014, US To reduce the likelihood of diagnostic error for patients presenting to ED Checklist via an audit system Non-randomised controlled trial Total sample size = 15 Used symptom specific checklist for high risk cases vulnerable for diagnostic error Used a general checklist ED ED clinicians Within the ED setting, checklists for diagnosis were helpful as they gave additional diagnostic possibilities and prevented diagnostic error
14 David et al., [37] 2011, US To improve skin infection missed diagnosis using Visual-based computerised diagnostic decision support system Computer assistance via an audit system Non-randomised observational descriptive Total sample size =145 Used Visual-based computerised diagnostic decision support system (VCDDSS) to diagnose skin infection ED (Dermatology) ED clinicians VCDDSS assisted primary care physicians to generate a more accurate diagnosis. Decision support tools should be included early in the diagnostic workflow to reduce misdiagnosis
15 Ramnarayan et al., [45] 2006, UK To determine if a web based reminder system assisted junior doctors to improve diagnostic error Computer assistance via an audit system Non-randomised observational cohort study Total sample size = 8995 Diagnostic decision support systems access attempts =595 Junior physicians were given access to a web based diagnostic aid system to provide diagnostic assistance Paediatrics Junior physicians A web-based diagnostic reminder system can successfully improve diagnostic decision making among junior doctors for acute paediatric assessments
16 Fridriksson et al., [40] 2001, Sweden To educate local doctors to bring patients with subarachnoid haemorrhage to immediate neurological attention Education program via an audit system Non-randomised prospective descriptive study Total sample size =187 Seminars and individual referred case follow-ups were established monthly Neurology Local physicians to neurologists including nursing staff Teaching programs focused on local physicians showed to have an impact on reducing diagnostic errors at low cost
17 Schriger et al., [46] 2001, US To determine if computerised psychiatric interview could increase the mental disease detection in ED Computer assistance via an audit system RCT Total sample size = 190 Intervention = 92 Control = 98 Patients with complaints associated with occult psychiatric illness were asked to complete the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire in the ED waiting room and randomly assigned to intervention and control groups. Intervention group -PRIME-MD diagnosis results were given to physician PRIME-MD diagnosis results were not given to the physician ED (Psychiatry) ED clinicians Patients willingly completed the questionnaire (median time 7 min) which frequently diagnosed psychiatric conditions. However, physicians rarely diagnosed or treated these conditions regardless of being provided by PRIME-ED diagnoses
18 Wellwood et al., [52], 1992, UK To increase accuracy in diagnosis of non-specific abdominal pain Computer assistance via an audit system Non-randomised cross over study Total sample size = 5193 Baseline: no diagnostic aid = 1610 Intervention 1 = 1598 Intervention 2 = 986 Intervention 3 = 999 Implementation of a computer aided system to increase accuracy in diagnosis of acute abdominal pain ED (Gastrointestinal) ED clinicians Routine use of structured data collection sheets to collect details of acute abdominal pain need serious consideration; computerized systems increase accuracy
19 Espinosa et al., [39] 2000, US To reduce clinically significant errors on radiographs interpreted in EDs Additional patient review via an audit system Non-randomised longitudinal study From, 1993 to 1994 = 28,161 1995 to 1996 = 20,236 1996 to 1999 = 67,111 ED physician performed immediate interpretation of all standard radiographs. A radiologist would provide an interpretation within 12 h as a quality control measure. Common errors in interpreting radiographs were discussed in a monthly meeting ED ED clinicians, radiologists Error rates were reduced significantly using radiograph systems of interpretation to optimise clinician skills
20 Soininen et al., [50] 2012, US To develop a versatile and objective computerised clinical decision support system for early detection of Alzheimer’s’ disease Computer assistance via an audit system Non-randomised observational descriptive study Total sample size = 400 A computer tool with composite disease indicators was implemented Psychiatry - Alzheimer’s disease Physicians The tool provided objective information for early detection and prediction of Alzheimer’s disease using visualised patient data
21 Sibbald et al., [49] 2013, Canada To determine if a checklist to interpret would improve diagnostic decision making Checklist via an audit system Non-randomised experimental control trial 15 clinicians interpreted 18 different ECGs under 4 conditions Clinicians were asked to provide a summative interpretation of 18 different ECGs under four conditions: (i) undirected; (ii) verification without a checklist; (iii) verification with a checklist, and (iv) interpretation and verification with a checklist) Cardiology Cardiology fellows Checklist use among ECG interpretation experts during the verification stage of diagnostic decisions did not increase cognitive load or cause expertise reversal, but reduced diagnostic error
22 Ely et al., [38] 2015, US To test a diagnostic checklist for common symptoms Checklist via an audit system RCT Total physician sample size =14 Intervention =7 Control n = 7 Total patient sample size =10 Intervention =53 Control =47 A checklist was provided to physicians with differential diagnosis for common presenting symptoms in primary care Usual diagnostic process ED Family physicians ED physicians Checklists did not improve the diagnostic error rate in the study
23 Sibbald et al., [48] 2013, Canada To evaluate checklists to improve cardiology diagnosis Checklist via an audit system RCT Total sample size = 191 Intervention =95 Control = 96 A simulator with six possible diagnosis was introduced. Residents examined the simulator as they examined a patient. Residents provided the diagnosis and estimate their certainty scale from 1 to 7. As the 2nd step intervention residents completed a checklist with re-examining the simulator Follow the first step same as the intervention group but in the 2nd step, completed the checklist without re-examining the simulator Cardiology Internal medicine-residents Verifying diagnostic decisions with checklists improved diagnostic accuracy. No evidence of increased cognitive load with use of checklists
24 Boguševičius et al., [35] 2002, Lithuania To compare computer aided diagnostic accuracy with contrast radiography to diagnose acute small bowel obstruction Computer assistance via an audit system RCT Total sample size = 80 Intervention = 40 Control = 40 Developed computer program assisted clinicians to make differential diagnosis of the character of mechanical small bowel obstruction Routine diagnosis without any computer aid Radiology Clinicians responsible for patient admission Computer aided diagnosis was not superior to radiology contrast but needed significantly less time to perform diagnosis
25 Howard et al., [42] 2006, US To implement a tertiary examination as standard care Additional patient review via an audit system Non-randomised observational prospective study Total sample size = 90 Introduction of a trauma tertiary exam form in addition to existing trauma history and physical examination forms ED (Trauma) Trauma nurse- specialists ED physicians Suggested adoption of tertiary examinations as standard of care for patients admitted to level II trauma centres
26 Jiang et al., [43] 2000, US To compare the effectiveness of independent double reading from computer support system and by radiologist Computer assistance via an audit system Non-randomised experimental study Total sample size = 104 Independent double reading and single-reading performance with a computer aid Radiology Radiologists Computer aided diagnosis was an effective tool to improve clinical radiology practice