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Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study
Christina L Cifra1,2, Jason W Custer3, Craig M Smith4
1Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA.
Insights
Diagnostic errors occurred in 1.5% of critically ill children admitted to the pediatric intensive care unit (PICU). Atypical presentations and diagnostic uncertainty were key factors, highlighting areas for improved diagnostic strategies.
Area of Science:
- Pediatric critical care medicine
- Patient safety research
- Diagnostic error analysis
Background:
- Diagnostic errors in pediatric intensive care units (PICUs) can impact patient outcomes.
- Understanding the prevalence and causes of these errors is crucial for developing effective interventions.
Purpose of the Study:
- To determine the prevalence and characteristics of diagnostic errors in critically ill children.
- To identify factors associated with diagnostic errors in the PICU setting.
Main Methods:
- A multicenter retrospective cohort study involving 882 pediatric patients admitted to four academic PICUs.
- Medical records were reviewed using the Revised Safer Dx instrument, with final determination by pediatric intensivists.
Main Results:
- A diagnostic error rate of 1.5% (13 of 882 admissions) was observed within 7 days of PICU admission.
- Infections and respiratory conditions were the most common missed diagnoses; one error led to prolonged hospitalization.
- Atypical presentations (OR 4.58) and diagnostic uncertainty on admission (OR 9.67) were significantly associated with diagnostic error.
Conclusions:
- Diagnostic errors affect a small but significant proportion of critically ill children in the PICUs.
- Interventions targeting diagnostic uncertainty and atypical presentations may reduce diagnostic errors in this population.
Objectives:
Effective interventions to prevent diagnostic error among critically ill children should be informed by diagnostic error prevalence and etiologies. We aimed to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU.
Design:
Multicenter retrospective cohort study using structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). Cases with potential errors were further reviewed by four pediatric intensivists who made final consensus determinations of diagnostic error occurrence. Demographic, clinical, clinician, and encounter data were also collected.
Setting:
Four academic tertiary-referral PICUs.
Patients:
Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs.
Interventions:
None.
Measurements And Main Results:
Of 882 patient admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission. Infections (46%) and respiratory conditions (23%) were the most common missed diagnoses. One diagnostic error caused harm with a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history (69%) and failure to broaden diagnostic testing (69%). Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%, p = 0.011), neurologic chief complaints (46.2% vs 18.8%, p = 0.024), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%, p = 0.042), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 wk, p = 0.031), and diagnostic uncertainty on admission (77% vs 25.1%, p < 0.001). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58; 95% CI, 0.94-17.1) and diagnostic uncertainty on admission (OR 9.67; 95% CI, 2.86-44.0) were significantly associated with diagnostic error.
Conclusions:
Among critically ill children, 1.5% had a diagnostic error up to 7 days after PICU admission. Diagnostic errors were associated with atypical presentations and diagnostic uncertainty on admission, suggesting possible targets for intervention.
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