Proposed system-related intervention ideas to address multiple dimensions of diagnostic error
| Intervention (suggested or tested) | Suggested | Tested |
| Patient-provider Encounter (n=2) | ||
| Trauma response team | Perno et al15 | |
| Comprehensive re-examination in the emergency department | Howard et al16 | |
| Diagnostic Test Performance and Interpretation (n=1) | ||
| Availability of electronic systems for results delivery | Weatherburn et al17 | |
| Follow-up and Tracking (n=15) | ||
| Explicit criteria for communication of abnormal test results | Gandhi,18 Hanna et al19 | |
| Planned follow-up to any test | Berner 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 information | Wahls and Cram27 | |
| Improve the management and presentation of test result data | Wahls and Cram27 | |
| Use the emergency department manager to monitor radiology test results reporting | Anon28 | |
| Report discrepancies in radiology reports to emergency department | Anon28 | |
| Establish back-up processes so that any information about test results can be easily retrieved again | Anon29 | |
| Establish highly structured hand-offs that are performed systematically | Anon29 | |
| Systematic tracking of diagnostic error in organisation | Colgan30; Schiff et al2 | |
| Referral related issues (n=1) | ||
| Ensure availability of appropriate expertise | Anon29 | |
| Patient related issues (n=18) | ||
| Address patient preferences for receiving test results | Leekha et al31; Meza and Webster32; Dolan et al33; Karnieli-Miller34; Keren et al35 | |
| Communicate normal test results | Baldwin et al36; Keren et al35 | |
| Use automated test results management tool | Matheny et al37 | |
| Use online portal to access test results | Wald et al38; Ross et al39 | |
| Provide access to entire medical record | Ross and Lin40 | |
| Consider cognitive limitations when taking patient history | Redelmeier et al41 | |
| Consider communication strategies to optimise patient understanding of medical information | Michie et al42; Lavin et al43 | |
| Enhance patient engagement in healthcare | Schwappach44; Longtin et al45 | |
| Greater involvement of patients to ensure the follow-up of test results | Wahls and Cram,27 Anon28 | |
| Patient navigator | Singh et al21 | |
| General interventions (n=12) | ||
| Provide education on error-producing conditions like fatigue | Caldwell46; Campbell et al47; Singh et al48; Beach et al49; Jones and Endsley50 Borrell-Carrio and Epstein51 | |
| Provide opportunity to correct last response | Fleck and Mitroff52 | |
| Address environmental conditions that could produce boredom, time pressure, etc | Tachakra53; Zwaan et al54 | |
| Use of information technology | Becich et al55; Singh et al56; Schiff and Bates22 | |