Table 3

Proposed system-related intervention ideas to address multiple dimensions of diagnostic error

Intervention (suggested or tested)SuggestedTested
Patient-provider Encounter (n=2)
 Trauma response teamPerno et al15
 Comprehensive re-examination in the emergency departmentHoward et al16
Diagnostic Test Performance and Interpretation (n=1)
 Availability of electronic systems for results deliveryWeatherburn et al17
Follow-up and Tracking (n=15)
 Explicit criteria for communication of abnormal test resultsGandhi,18 Hanna et al19
 Planned follow-up to any testBerner and Graber,1 Schiff20
 Test-tracking system for ordering providers (electronic or not)Gandhi,18 Singh et al,21 Schiff and Bates 22; Casalino et al23;Singh et al24; Poon et al,25 Piva et al26
 Improved standardisation of the steps involved in the flow of test result informationWahls and Cram27
 Improve the management and presentation of test result dataWahls and Cram27
 Use the emergency department manager to monitor radiology test results reportingAnon28
 Report discrepancies in radiology reports to emergency departmentAnon28
 Establish back-up processes so that any information about test results can be easily retrieved againAnon29
 Establish highly structured hand-offs that are performed systematicallyAnon29
 Systematic tracking of diagnostic error in organisationColgan30; Schiff et al2
Referral related issues (n=1)
 Ensure availability of appropriate expertiseAnon29
Patient related issues (n=18)
 Address patient preferences for receiving test resultsLeekha et al31; Meza and Webster32; Dolan et al33; Karnieli-Miller34; Keren et al35
 Communicate normal test resultsBaldwin et al36; Keren et al35
 Use automated test results management toolMatheny et al37
 Use online portal to access test resultsWald et al38; Ross et al39
 Provide access to entire medical recordRoss and Lin40
 Consider cognitive limitations when taking patient historyRedelmeier et al41
 Consider communication strategies to optimise patient understanding of medical informationMichie et al42; Lavin et al43
 Enhance patient engagement in healthcareSchwappach44; Longtin et al45
 Greater involvement of patients to ensure the follow-up of test resultsWahls and Cram,27 Anon28
 Patient navigatorSingh et al21
General interventions (n=12)
 Provide education on error-producing conditions like fatigueCaldwell46; Campbell et al47; Singh et al48; Beach et al49; Jones and Endsley50 Borrell-Carrio and Epstein51
 Provide opportunity to correct last responseFleck and Mitroff52
 Address environmental conditions that could produce boredom, time pressure, etcTachakra53; Zwaan et al54
 Use of information technologyBecich et al55; Singh et al56; Schiff and Bates22