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PRISMA, or the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, provides guidance on what minimum information should be included in your review. The PRISMA flow diagram walks the reader through your search and review process, with an aim towards thorough and transparent research. 

Don't forget, if you're using Covidence for your literature review, a PRISMA diagram will be generated for you to double-check. 

PRISMA Flow Diagram Step-by-Step Instructions

Step 1: Preparation To complete the the PRISMA Flow Diagram print out a copy of the diagram to use alongside your searches. A downloadable template of the diagram is available on my SON page in the Primary Research Tools box.  

Step 2: Doing the database search Search all databases using your search strategy. Combine all the search terms using boolean operators like AND or OR as appropriate. Create subcollections in Zotero under the parent folder for each database that you are using (e.g. PubMed, CINAHL, Web of Science, etc.).  Use the Zotero web connector to export citations for each database into the corresponding subcollection.  (If Zotero web connector isn't working, export citations using the RIS format, then import file into Zotero.)  Go to Zotero main menu bar and select View, then select Show Items in Subcollections.  Now you can see the entire collections of citations from the databases.  Record the total number of citations and enter the number in the top left box of the PRISMA Flow Diagram.

PRISMA additional sources


Step 3: Additional sources If you found additional articles outside of your database searches, like manual searches through reference lists of articles you have found (citation chaining), grey literature or Google Scholar, then enter the total number of records in the box on the top right of the flow diagram.

PRISMA diagram showing duplicates removed box


Step 4: Remove all duplicates In Zotero, merge duplicates by selecting Duplicate Items (located under list of collections) and keep merging until all citations are removed from the center panel. Enter the number of remaining citations after you have removed the duplicates.

PRISMA records screened


Step 5: Screening articles The next step is to add in the number of articles that you have screened. This is the same number that you entered in the duplicates removed box.

PRISMA records excluded box


Step 6: Screening - Excluded articles Begin the screening process by looking at the titles and abstracts for all articles.  Use your inclusion/exclusion criteria to determine which articles are relevant to your research question. The screening process can made easier by using a tagging system in Zotero to keep track of your actions.  Create tags for INCLUDE, MAYBE, EXCLUDE, and FINAL ARTICLES and assign them a color.  Note that assigning a tag a color also assigns it a number.  Therefore, you can enter the assigned number on your keyboard to insert a tag.  Any articles that appear to help you provide an answer to your research question should be included in the initial title/abstract screen. Citations tagged with MAYBE should also be included.  Record the number of articles excluded (citations with red tag) based on this screening process in the appropriate box (next to the total number of screened records). 

PRISMA eligability box


Step 7: Eligibility Subtract the number of excluded articles following the screening phase (step 6) from the total number of records screened (step 5) and enter this number in the box titled "Full-text articles assessed for eligibility". Get the full text article for all citations with a green or blue tag to review for eligibility.  (In Zotero, full text articles can be retrieved by selecting Library Lookup, which can be found in the drop-down menu under the right arrow.)  Use the library's free interlibrary loan service to obtain articles not in the UVA collection. 

PRISMA full text articles excluded


Step 8: Eligibility - Records excluded Review all full-text articles for eligibility.  Tag citations excluded in the full-text screen by adding a EXCLUDE tag and add a note in the record explaining why you excluded it. Examples include wrong setting, wrong patient population, wrong intervention, wrong dosage, not US, not right age group, etc.  All articles that make it through the full-text review should be tagged FINAL ARTICLES.  Create a new sub-collection in the parent folder and name it FINAL ARTICLES  All articles that make it through the eligibility process can be moved into the FINAL ARTICLES sub-collection.

PRISMA articles excluded


Step 9: Included The final step is to subtract the number of excluded articles or records during the eligibility review of full-text (step 8) from the total number of articles reviewed for eligibility (step 7). Enter this number in the last box.  You have now completed your PRISMA Flow Diagram which you can now include in the results section of your article or assignment.

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