Open Access Highly Accessed Research article

Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study

Padmanabhan Ramnarayan1*, Graham C Roberts2, Michael Coren3, Vasantha Nanduri4, Amanda Tomlinson5, Paul M Taylor6, Jeremy C Wyatt7 and Joseph F Britto5

Author Affiliations

1 Children's Acute Transport Service (CATS), 44B Bedford Row, London, WC1H 4LL, UK

2 Department of Paediatric Allergy and Respiratory Medicine, Southampton University Hospital Trust, Tremona Road, Southampton, SO16 6YD, UK

3 Department of Paediatrics, St Mary's Hospital, Paddington, London, W2 1NY, UK

4 Department of Paediatrics, Watford General Hospital, Vicarage Road, Watford, WD18 0HB, UK

5 Isabel Healthcare Ltd, Po Box 244, Haslemere, Surrey, GU27 1WU, UK

6 Centre for Health Informatics and Multiprofessional Education (CHIME), Archway Campus, Highgate Hill, London, N19 5LW, UK

7 Health Informatics Centre, The Mackenzie Building, University of Dundee, Dundee, DD2 4BF, UK

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BMC Medical Informatics and Decision Making 2006, 6:22  doi:10.1186/1472-6947-6-22

Published: 28 April 2006



Computerized decision support systems (DSS) have mainly focused on improving clinicians' diagnostic accuracy in unusual and challenging cases. However, since diagnostic omission errors may predominantly result from incomplete workup in routine clinical practice, the provision of appropriate patient- and context-specific reminders may result in greater impact on patient safety. In this experimental study, a mix of easy and difficult simulated cases were used to assess the impact of a novel diagnostic reminder system (ISABEL) on the quality of clinical decisions made by various grades of clinicians during acute assessment.


Subjects of different grades (consultants, registrars, senior house officers and medical students), assessed a balanced set of 24 simulated cases on a trial website. Subjects recorded their clinical decisions for the cases (differential diagnosis, test-ordering and treatment), before and after system consultation. A panel of two pediatric consultants independently provided gold standard responses for each case, against which subjects' quality of decisions was measured. The primary outcome measure was change in the count of diagnostic errors of omission (DEO). A more sensitive assessment of the system's impact was achieved using specific quality scores; additional consultation time resulting from DSS use was also calculated.


76 subjects (18 consultants, 24 registrars, 19 senior house officers and 15 students) completed a total of 751 case episodes. The mean count of DEO fell from 5.5 to 5.0 across all subjects (repeated measures ANOVA, p < 0.001); no significant interaction was seen with subject grade. Mean diagnostic quality score increased after system consultation (0.044; 95% confidence interval 0.032, 0.054). ISABEL reminded subjects to consider at least one clinically important diagnosis in 1 in 8 case episodes, and prompted them to order an important test in 1 in 10 case episodes. Median extra time taken for DSS consultation was 1 min (IQR: 30 sec to 2 min).


The provision of patient- and context-specific reminders has the potential to reduce diagnostic omissions across all subject grades for a range of cases. This study suggests a promising role for the use of future reminder-based DSS in the reduction of diagnostic error.