Kathryn M. McDonald, MM; Brian Matesic, BS; Despina G. Contopoulos-Ioannidis, MD; Julia Lonhart, BS, BA; Eric Schmidt, BA; Noelle Pineda, BA; John P.A. Ioannidis, MD, DSc
Note: The AHRQ reviewed contract deliverables to ensure adherence to contract requirements and quality, and a copyright release was obtained from the AHRQ before the manuscript was submitted for publication.
Disclaimer: All statements expressed in this work are those of the authors and should not in any way be construed as official opinions or positions of Stanford University, the AHRQ, or the U.S. Department of Health and Human Services.
Financial Support: From the AHRQ, U.S. Department of Health and Human Services (contract HHSA-290-2007-100621).
Potential Conflicts of Interest: Ms. McDonald: Grant (money to institution): AHRQ. Mr. Schmidt: Grant (money to institution): AHRQ. All other authors had no disclosures to report. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOflnterestForms.do?msNum=M12-2571.
Requests for Single Reprints: Kathryn M. McDonald, MM, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019; e-mail, Kathryn.McDonald@stanford.edu.
Current Author Addresses: Ms. McDonald, Ms. Lonhart, and Mr. Schmidt: Stanford Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.
Mr. Matesic and Ms. Pineda: School of Medicine, Stanford University, 291 Campus Drive, Stanford, CA 94305.
Dr. Contopoulos-Ioannidis: Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, 300 Pasteur Drive, G312, Stanford, CA 94305.
Dr. Ioannidis: Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, 1265 Welch Road, X306, Stanford, CA 94305.
Author Contributions: Conception and design: K.M. McDonald, B. Matesic, D.G. Contopoulos-Ioannidis, J. Lonhart, J.P.A. Ioannidis.
Analysis and interpretation of the data: K.M. McDonald, B. Matesic, D.G. Contopoulos-Ioannidis, J. Lonhart, E. Schmidt, J.P.A. Ioannidis.
Drafting of the article: K.M. McDonald, B. Matesic, D.G. Contopoulos-Ioannidis, J. Lonhart, E. Schmidt, J.P.A. Ioannidis.
Critical revision of the article for important intellectual content: K.M. McDonald, B. Matesic, D.G. Contopoulos-Ioannidis, J.P.A. Ioannidis.
Final approval of the article: K.M. McDonald, B. Matesic, D.G. Contopoulos-Ioannidis, J. Lonhart, E. Schmidt, N. Pineda, J.P.A. Ioannidis.
Provision of study materials or patients: J. Lonhart.
Statistical expertise: D.G. Contopoulos-Ioannidis, J.P.A. Ioannidis.
Obtaining of funding: K.M. McDonald.
Administrative, technical, or logistic support: K.M. McDonald, B. Matesic, J. Lonhart, E. Schmidt, N. Pineda.
Collection and assembly of data: K.M. McDonald, B. Matesic, J. Lonhart, E. Schmidt, N. Pineda, J.P.A. Ioannidis.
Missed, delayed, or incorrect diagnosis can lead to inappropriate patient care, poor patient outcomes, and increased cost. This systematic review analyzed evaluations of interventions to prevent diagnostic errors. Searches used MEDLINE (1966 to October 2012), the Agency for Healthcare Research and Quality's Patient Safety Network, bibliographies, and prior systematic reviews. Studies that evaluated any intervention to decrease diagnostic errors in any clinical setting and with any study design were eligible, provided that they addressed a patient-related outcome. Two independent reviewers extracted study data and rated study quality.
There were 109 studies that addressed 1 or more intervention categories: personnel changes (n = 6), educational interventions (n = 11), technique (n = 23), structured process changes (n = 27), technology-based systems interventions (n = 32), and review methods (n = 38). Of 14 randomized trials, which were rated as having mostly low to moderate risk of bias, 11 reported interventions that reduced diagnostic errors. Evidence seemed strongest for technology-based systems (for example, text message alerting) and specific techniques (for example, testing equipment adaptations). Studies provided no information on harms, cost, or contextual application of interventions. Overall, the review showed a growing field of diagnostic error research and categorized and identified promising interventions that warrant evaluation in large studies across diverse settings.
Table. Categories of Organizational Interventions to Decrease Diagnostic Errors
Interventions, by type.
The percentage of studies as categorized by the 6 types of interventions.
Intervention studies, by year.
Timeline of the included studies categorized by the 6 types of interventions.
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Elisa Piva, MD, Mario Plevani, MD
University Hospital Padova, Italy
July 29, 2013
The paper by Kathryn M McDonald et al. deals with the topic of patient safety strategies which aim to reduce diagnostic errors. Given the complexity of the issue and the nature of diagnostic errors, the key point that “approaches to reduce errors may involve technical, cognitive, and system-oriented strategies tailored to specific conditions or settings” (1) represents a crucial strategy with which we are complete agreement. Focusing on technology-based systems interventions, a body of evidence has been collected to demonstrate the importance of timely and safe notification of laboratory critical values to clinicians. The Joint Commission (2) and many accreditation agencies (3) agree that critical value reporting is an important mission of clinical laboratory. More recently, the possible harmonization of existing policies, based on robust evidence, has been advocated for improving quality and patient safety (4). However, there are few reports on the relationship between the notification of critical values, clinicians’ reaction and improved clinical outcomes. We recently performed a clinical audit aimed at evaluating the effectiveness of a computerized notification system in reporting critical values within our University-Hospital as previously described (5). In particular, we evaluated over 200 critical values over a three-month period for inpatients, of which 75% were from Internal Medicine Departments and 25% from Surgical Departments. In both settings, 43% of the critical values were unexpected by clinicians and the therapy was modified in 90% of the patients admitted to the Internal Medicine wards, and in 96% of the patients in the Surgery department, respectively. Our data underline the importance of timely and safe notification of critical values to clinical outcomes, namely immediate changes in therapy or patient management and as a quality indicator in laboratory medicine. Therefore, timeliness of laboratory results, especially for critical values and critical tests, should always be correlated with clinical effectiveness, and procedures should provide the best clinical outcomes at the lowest reasonable cost. Further initiatives to promote the harmonization of laboratory practices, including the reporting of critical values, should help to further improve the quality of care and patient safety.Elisa Piva and Mario PlebaniDepartment of Laboratory Medicine, University-Hospital, Padova, ItalyReferences1. McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, PinedaN, Ioannidis JP. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med. 2013 ;158:381-9. 2. Singh H, Vij MS. Eight recommendations for policies for communicating abnormal test results. Jt Comm J Qual Patient Saf. 2010; 36:226-32.3. International Organization for Standardization. ISO 15189:2012: Medical laboratories: particular requirements for quality and competence. Geneva, Switzerland: International Organization for Standardization; 2012.4. Plebani M. Harmonization in laboratory medicine: the complete picture. Clin Chem Lab Med. 2013; 51:741-51.5. Piva E, Sciacovelli L, Zaninotto M, Laposata M, Plebani M. Evaluation of effectiveness of a computerized notification system for reporting critical values. Am J Clin Pathol. 2009;131:43
McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, et al. Patient Safety Strategies Targeted at Diagnostic Errors: A Systematic Review. Ann Intern Med. ;158:381–389. doi: 10.7326/0003-4819-158-5-201303051-00004
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Published: Ann Intern Med. 2013;158(5_Part_2):381-389.
Healthcare Delivery and Policy, Prevention/Screening.
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