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System-related interventions to reduce diagnostic errors: a narrative review
  1. Hardeep Singh1,2,
  2. Mark L Graber3,
  3. Stephanie M Kissam3,
  4. Asta V Sorensen3,
  5. Nancy F Lenfestey3,
  6. Elizabeth M Tant3,
  7. Kerm Henriksen4,
  8. Kenneth A LaBresh3
  1. 1Houston VA Health Services R&D Center of Excellence, and the Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
  2. 2Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  3. 3RTI International, Research Triangle Park, North Carolina, USA
  4. 4Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland, USA
  1. Correspondence to Hardeep Singh, Section of Health Services Research, Baylor College of Medicine, 2002 Holcombe Blvd, VAMC 152, Houston, TX 77030, USA; hardeeps{at}


Background Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic errors.

Methods The authors conducted a comprehensive search using multiple search strategies. First, they performed a PubMed search to identify articles exclusively related to diagnostic error or delay published in English between 2000 and 2009. They then sought papers from references in the initial dataset, searches of additional databases, and subject matter experts. Articles were included if they formally evaluated an intervention to prevent or reduce diagnostic error; however, papers were also included if interventions were suggested and not tested to inform the state of the science on the subject. Interventions were characterised according to the step in the diagnostic process they targeted: patient–provider encounter; performance and interpretation of diagnostic tests; follow-up and tracking of diagnostic information; subspecialty and referral-related issues; and patient-specific care-seeking and adherence processes.

Results 43 articles were identified for full review, of which six reported tested interventions and 37 contained suggestions for possible interventions. Empirical studies, although somewhat positive, were non-experimental or quasi-experimental and included a small number of clinicians or healthcare sites. Outcome measures in general were underdeveloped and varied markedly among studies, depending on the setting or step in the diagnostic process.

Conclusions Despite a number of suggested interventions in the literature, few empirical studies in the past decade have tested interventions to reduce diagnostic errors. Advancing the science of diagnostic error prevention will require more robust study designs and rigorous definitions of diagnostic processes and outcomes to measure intervention effects.

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  • The authors of this paper are solely responsible for its content. The findings and interpretations in the paper do not represent the opinions or recommendations of the institutions with which the authors are affiliated, the Agency for Healthcare Research and Quality, the NIH or the US Department of Health and Human Services.

  • Funding This study was funded by the Agency for Healthcare Research and Quality (AHRQ) Task Order Contract No. HHSA290200600001, Task 8. Dr Singh is additionally supported by an NIH K23 career development award (K23CA125585), the VA National Center of Patient Safety, Agency for Health Care Research and Quality, and in part by the Houston VA HSR&D Center of Excellence (HFP90-020).

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.