Table 1 Diagnostic error prevention 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