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Updated: Oct 1, 2025

Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography
Published on: January 27, 2023
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study
Grant J Shafer1,2, Hardeep Singh3,4, Eric J Thomas5,6
1Children's Hospital of Orange County, Orange, CA, USA. grant.shafer421@gmail.com.
Objective:
To determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients.
Study Design:
We conducted a retrospective cohort study of 600 consecutive inborn admissions. A physician used the "Safer Dx NICU Instrument" to review the electronic health record for the first 7 days of admission, and categorized cases as "yes," "unclear," or "no" for diagnostic error. A secondary reviewer evaluated all "yes" charts plus a random sample of charts in the other categories. Subsequently, all secondary reviewers reviewed records with discordance between primary and secondary review to arrive at consensus.
Results:
We identified 37 diagnostic errors (6.2% of study patients) with "substantial agreement" between reviewers (κ = 0.66). The most common diagnostic process breakdown was missed maternal history (51%).
Conclusion:
The frequency of diagnostic error in inborn NICU patients during the first 7 days of admission is 6.2%.
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