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Use of e-triggers to identify diagnostic errors in the paediatric ED
Daniel Lam1, Fidelity Dominguez2, Jan Leonard3
1Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA daniel.lam@childrenscolorado.org.
Insights
Electronic triggers (e-triggers) effectively identify diagnostic errors (DxEs) in children admitted after an emergency department (ED) visit. Existing reporting systems miss most DxEs, highlighting the need for improved surveillance in pediatric care.
Area of Science:
- Pediatric Healthcare
- Patient Safety
- Diagnostic Accuracy
Background:
- Diagnostic errors (DxEs) are a significant cause of patient harm in children, yet are underreported.
- Current adverse event reporting systems fail to capture most pediatric DxEs.
- Electronic triggers (e-triggers) show promise for identifying DxEs but haven't been applied in emergency departments (EDs).
Purpose of the Study:
- To evaluate an e-trigger and manual screening for identifying probable DxEs in children with unplanned admissions after an ED visit.
- To compare the e-trigger's performance against existing incident reporting systems.
Main Methods:
- Retrospective cohort study of children (0-22 years) admitted within 14 days of an ED visit (2018-2019).
- E-trigger identified patients; manual screening assessed diagnostic discrepancies.
- SaferDx Instrument used for DxE review; cases cross-referenced with incident reporting systems.
Main Results:
- E-trigger identified 1915 unplanned admissions (7.7%).
- 92 probable DxEs were identified (0.4% of all admissions, 20.3% of screened cases).
- Existing systems captured only 6.5% of identified DxEs.
Conclusions:
- E-trigger with manual screening effectively identifies children at risk for DxEs.
- Current surveillance systems significantly underreport pediatric DxEs.
- Further research needed to pinpoint specific clinical presentations prone to DxEs.
Background:
Diagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting.
Objectives:
To assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems.
Design/Methods:
Retrospective single-centre cohort study of children ages 0-22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems.
Results:
An e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen's κ=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital's incident reporting system and five to the ED case review team (one reported to both).
Conclusion:
An e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs.
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