Checklists to reduce diagnostic error: a systematic review of the literature using a human factors framework

Abstract

ObjectivesTo apply a human factors framework to understand whether checklists reduce clinical diagnostic error have (1) gaps in composition; and (2) components that may be more likely to reduce errors.DesignSystematic review.Data sourcesPubMed, EMBASE, Scopus and Web of Science were searched through 15 February 2022.Eligibility criteriaAny article that included a clinical checklist aimed at improving the diagnostic process. Checklists were defined as any structured guide intended to elicit additional thinking regarding diagnosis.Data extraction and synthesisTwo authors independently reviewed and selected articles based on eligibility criteria. Each extracted unique checklist was independently characterised according to the well-established human factors framework: Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0). If reported, checklist efficacy in reducing diagnostic error (eg, diagnostic accuracy, number of errors or any patient-related outcomes) was outlined. Risk of study bias was independently evaluated using standardised quality assessment tools in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses.ResultsA total of 30 articles containing 25 unique checklists were included. Checklists were characterised within the SEIPS 2.0 framework as follows: Work Systems subcomponents of Tasks (n=13), Persons (n=2) and Internal Environment (n=3); Processes subcomponents of Cognitive (n=20) and Social and Behavioural (n=2); and Outcomes subcomponents of Professional (n=2). Other subcomponents, such as External Environment or Patient outcomes, were not addressed. Fourteen checklists examined effect on diagnostic outcomes: seven demonstrated improvement, six were without improvement and one demonstrated mixed results. Importantly, Tasks-oriented studies more often demonstrated error reduction (n=5/7) than those addressing the Cognitive process (n=4/10).ConclusionsMost diagnostic checklists incorporated few human factors components. Checklists addressing the SEIPS 2.0 Tasks subcomponent were more often associated with a reduction in diagnostic errors. Studies examining less explored subcomponents and emphasis on Tasks, rather than the Cognitive subcomponents, may be warranted to prevent diagnostic errors.

Diagnostic delays among COVID‐19 patients with a second concurrent diagnosis

“…31 These checklists incorporate human and situational factors that might be adapted to pandemic settings. 32 Another promising tool is the electronic triggering system that analyzes patient characteristics to identify high-risk patients for the diagnostic delay. This intervention was shown to reduce time to diagnosis of cancer in a primary care setting, and has shown promising results in the emergency room setting.…”

“…Cognitive checklists have been shown to improve outcomes in error‐prone processes 31 . These checklists incorporate human and situational factors that might be adapted to pandemic settings 32 . Another promising tool is the electronic triggering system that analyzes patient characteristics to identify high‐risk patients for the diagnostic delay.…”

Managing Interruptions to Improve Diagnostic Decision-Making: Strategies and Recommended Research Agenda

“…25 Additionally, this leads us to question whether interruptions are more or less likely to be deleterious at different points in the process, an idea we return to in the "Future Directions" section. While there is promising evidence for the effectiveness of checklists in medicine, 27 more research is needed within diagnosis to better understand how checklists can impact clinical decision-making and particularly how checklists may be able to mitigate errors caused by interruptions.…”