Diagnostic errors with inserted tubes, lines and catheters in children

Tubes and catheters are frequently used in the care of hospitalized children. Yet little is known about errors in diagnosis in commonly implanted devices in a pediatric population.

The purpose of this study was to determine the frequency and range of diagnostic errors with inserted devices in a pediatric population.

During a 9-year period 142,041 cases were reviewed as part of our ongoing quality-assurance process. Of 4,084 disagreements in diagnosis encountered, 50 cases with diagnostic errors related to endovascular catheters, gastrointestinal, genitourinary and neurosurgical tubes, and pacemaker wires were identified and retrospectively reviewed. Diagnostic error was defined as a diagnosis that was unintentionally delayed, wrong or missed. These errors were classified as perceptual, cognitive, system-related or unavoidable and were graded according to potential clinical impact using a scale from 1 to 4, with 4 being the most serious.

Device-related diagnostic errors accounted for 1.2% of all discrepancies identified and 10% of errors potentially leading to a change in therapy. Seventeen of the 50 diagnostic errors were related to vascular catheters (34%), including wrong anatomical location of catheter tip (12) and missed catheter fracture or migration (5). Twenty-seven errors (54%) were related to non-vascular catheters and involved enteric tube location (15), ventricular drainage catheters (7), endotracheal tubes (3) and genitourinary catheters (2). Six additional errors involved a vascular stent, endovascular cuff, needle, chest tube and epicardial wire placement (2).

Device-related diagnostic errors are not frequent in complex pediatric patients. However, they can have a clinically significant impact on patient outcomes and management. High-risk situations include altered patient anatomy, poor or limited image quality, inconspicuous lines and incomplete review of prior studies.