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Finding Diagnostic Errors in Children Admitted to the PICU
Maria Caridad Davalos1, Kenya Samuels, Ashley N D Meyer
11Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX. 2Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX. 3Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX.
Insights
The Safer Dx Instrument reliably detects diagnostic errors in pediatric intensive care units (PICUs). This tool can improve diagnostic safety for high-risk children.
Area of Science:
- Pediatric critical care medicine
- Diagnostic error analysis
- Patient safety research
Background:
- Diagnostic errors are a significant concern in healthcare.
- The Safer Dx Instrument was developed to identify diagnostic errors in primary care.
- Its utility in specialized settings like the Pediatric Intensive Care Unit (PICU) is not well-established.
Purpose of the Study:
- To evaluate the reliability and validity of the Safer Dx Instrument for detecting diagnostic errors in high-risk PICU patients.
- To assess the feasibility of using this structured tool in a critical care environment.
Main Methods:
- The Safer Dx Instrument, comprising 12 questions, was applied to retrospectively analyze records of four high-risk patient cohorts admitted to the PICU.
- High-risk cohorts included patients who underwent autopsy, recent outpatients, and those unexpectedly transferred to the PICU.
- Two independent clinicians reviewed patient records for diagnostic errors, with confirmation by senior experts.
Main Results:
- Diagnostic errors were identified in 12.1% of 214 high-risk PICU patient records.
- Error rates varied by cohort, with the highest observed in patients unexpectedly transferred to the PICU (29.5%).
- The most frequent missed diagnoses were infections and neurologic conditions.
Conclusions:
- The Safer Dx Instrument demonstrates high reliability and validity for identifying diagnostic errors in high-risk pediatric critical care settings.
- This tool holds potential for enhancing diagnostic safety and feedback mechanisms in pediatric care.
- Further validation in diverse clinical settings is recommended.
Objectives:
To determine whether the Safer Dx Instrument, a structured tool for finding diagnostic errors in primary care, can be used to reliably detect diagnostic errors in patients admitted to a PICU.
Design And Setting:
The Safer Dx Instrument consists of 11 questions to evaluate the diagnostic process and a final question to determine if diagnostic error occurred. We used the instrument to analyze four "high-risk" patient cohorts admitted to the PICU between June 2013 and December 2013.
Patients:
High-risk cohorts were defined as cohort 1: patients who were autopsied; cohort 2: patients seen as outpatients within 2 weeks prior to PICU admission; cohort 3: patients transferred to PICU unexpectedly from an acute care floor after a rapid response and requiring vasoactive medications and/or endotracheal intubation due to decompensation within 24 hours; and cohort 4: patients transferred to PICU unexpectedly from an acute care floor after a rapid response without subsequent decompensation in 24 hours.
Interventions:
Two clinicians used the instrument to independently review records in each cohort for diagnostic errors, defined as missed opportunities to make a correct or timely diagnosis. Errors were confirmed by senior expert clinicians.
Measurements And Main Results:
Diagnostic errors were present in 26 of 214 high-risk patient records (12.1%; 95% CI, 8.2-17.5%) with the following frequency distribution: cohort 1: two of 16 (12.5%); cohort 2: one of 41 (2.4%); cohort 3: 13 of 44 (29.5%); and cohort 4: 10 of 113 (8.8%). Overall initial reviewer agreement was 93.6% (κ, 0.72). Infections and neurologic conditions were the most commonly missed diagnoses across all high-risk cohorts (16/26).
Conclusions:
The Safer Dx Instrument has high reliability and validity for diagnostic error detection when used in high-risk pediatric care settings. With further validation in additional clinical settings, it could be useful to enhance learning and feedback about diagnostic safety in children.
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