A macro-ergonomic work system analysis of the diagnostic testing process in an outpatient health care facility for process improvement and patient safety

Ergonomics. 2006;49(5-6):544-66. doi: 10.1080/00140130600568832.


The diagnosis of illness is important for quality patient care and patient safety and is greatly aided by diagnostic testing. For diagnostic tests, such as pathology and radiology, to positively impact patient care, the tests must be processed and the physician and patient must be notified of the results in a timely fashion. There are many steps in the diagnostic testing process, from ordering to result dissemination, where the process can break down and therefore delay patient care and reduce patient safety. This study was carried out to examine the diagnostic testing process (i.e. from ordering to result notification) and used a macro-ergonomic work system analysis to uncover system design flaws that contributed to delayed physician and patient notification of results. The study was carried out in a large urban outpatient health-care facility made up of 30 outpatient clinics. Results indicated a number of variances that contributed to delays, the majority of which occurred across the boundaries of different systems and were related to poor or absent feedback structures. Recommendations for improvements are discussed.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Diagnostic Errors / classification
  • Diagnostic Errors / prevention & control*
  • Diagnostic Tests, Routine / standards*
  • Ergonomics*
  • Hospitals, Teaching
  • Humans
  • Interviews as Topic
  • Organizational Culture
  • Outpatient Clinics, Hospital / organization & administration
  • Outpatient Clinics, Hospital / standards*
  • Outpatients
  • Quality Assurance, Health Care*
  • Risk Management
  • Safety Management / standards*
  • Software Design
  • Task Performance and Analysis*
  • Wisconsin