1
|
Leulseged H, Bethencourt C, Igunza KA, Akelo V, Onyango D, Omore R, Ogbuanu IU, Ameh S, Moseray A, Kowuor D, Bassey IA, El Arifeen S, Gurley ES, Hossain MZ, Rahman A, Alam M, Assefa N, Madrid L, Alemu A, Abdullahi YY, Kotloff KL, Sow SO, Tapia MD, Kourouma N, Sissoko S, Bassat Q, Varo R, Mandomando I, Carrilho C, Rakislova N, Fernandes F, Madhi S, Dangor Z, Mahtab S, Hale M, Baillie V, du Toit J, Madewell ZJ, Blau DM, Martines RB, Mutevedzi PC, Breiman RF, Whitney CG, Rees CA. Clinicopathological discrepancies in the diagnoses of childhood causes of death in the CHAMPS network: An analysis of antemortem diagnostic inaccuracies. BMJ Paediatr Open 2024; 8:e002654. [PMID: 39032935 DOI: 10.1136/bmjpo-2024-002654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/04/2024] [Indexed: 07/23/2024] Open
Abstract
INTRODUCTION Determining aetiology of severe illness can be difficult, especially in settings with limited diagnostic resources, yet critical for providing life-saving care. Our objective was to describe the accuracy of antemortem clinical diagnoses in young children in high-mortality settings, compared with results of specific postmortem diagnoses obtained from Child Health and Mortality Prevention Surveillance (CHAMPS). METHODS We analysed data collected during 2016-2022 from seven sites in Africa and South Asia. We compared antemortem clinical diagnoses from clinical records to a reference standard of postmortem diagnoses determined by expert panels at each site who reviewed the results of histopathological and microbiological testing of tissue, blood, and cerebrospinal fluid. We calculated test characteristics and 95% CIs of antemortem clinical diagnostic accuracy for the 10 most common causes of death. We classified diagnostic discrepancies as major and minor, per Goldman criteria later modified by Battle. RESULTS CHAMPS enrolled 1454 deceased young children aged 1-59 months during the study period; 881 had available clinical records and were analysed. The median age at death was 11 months (IQR 4-21 months) and 47.3% (n=417) were female. We identified a clinicopathological discrepancy in 39.5% (n=348) of deaths; 82.3% of diagnostic errors were major. The sensitivity of clinician antemortem diagnosis ranged from 26% (95% CI 14.6% to 40.3%) for non-infectious respiratory diseases (eg, aspiration pneumonia, interstitial lung disease, etc) to 82.2% (95% CI 72.7% to 89.5%) for diarrhoeal diseases. Antemortem clinical diagnostic specificity ranged from 75.2% (95% CI 72.1% to 78.2%) for diarrhoeal diseases to 99.0% (95% CI 98.1% to 99.6%) for HIV. CONCLUSIONS Antemortem clinical diagnostic errors were common for young children who died in areas with high childhood mortality rates. To further reduce childhood mortality in resource-limited settings, there is an urgent need to improve antemortem diagnostic capability through advances in the availability of diagnostic testing and clinical skills.
Collapse
Affiliation(s)
- Haleluya Leulseged
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Hararghe Health Research, Haramaya University, Harar, Ethiopia
- London School of Hygiene & Tropical Medicine, London, UK
| | - Christine Bethencourt
- Children's Hospital of Philadelphia Pediatrics Residency Program, Philadelphia, Pennsylvania, USA
| | | | - Victor Akelo
- Liverpool School of Tropical Medicine, Liverpool, UK
- Global Health Institute, Emory University, Atlanta, Georgia, USA
| | | | - Richard Omore
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Ikechukwu U Ogbuanu
- Crown Agents, Freetown, Sierra Leone
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Soter Ameh
- Crown Agents, Freetown, Sierra Leone
- Department of Community Medicine, University of Calabar, Calabar, Cross River, Nigeria
- Bernard Lown Scholars Program in Cardiovascular Health, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Emily S Gurley
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Afruna Rahman
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Muntasir Alam
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Nega Assefa
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- London School of Hygiene & Tropical Medicine, London, UK
| | - Lola Madrid
- London School of Hygiene & Tropical Medicine, London, UK
| | - Addisu Alemu
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Yasir Y Abdullahi
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Karen L Kotloff
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Samba O Sow
- Centre pour le Développement des Vaccins-Mali, Bamako, Mali
| | - Milagritos D Tapia
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nana Kourouma
- Centre pour le Développement des Vaccins-Mali, Bamako, Mali
| | - Seydou Sissoko
- Centre pour le Développement des Vaccins-Mali, Bamako, Mali
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Rosauro Varo
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Inacio Mandomando
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Carla Carrilho
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Department of Pathology, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Natalia Rakislova
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Fabiola Fernandes
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Department of Pathology, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Shabir Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Martin Hale
- Department of Anatomical Pathology, University of the Witwatersrand Johannesburg, Johannesburg, South Africa
| | - Vicky Baillie
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeanie du Toit
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Zachary J Madewell
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dianna M Blau
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Roosecelis B Martines
- Infectious Diseases Pathology Branch, NCEZID, DHCPP, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Chris A Rees
- Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Cifra CL, Custer JW, Smith CM, Smith KA, Bagdure DN, Bloxham J, Goldhar E, Gorga SM, Hoppe EM, Miller CD, Pizzo M, Ramesh S, Riffe J, Robb K, Simone SL, Stoll HD, Tumulty JA, Wall SE, Wolfe KK, Wendt L, Eyck PT, Landrigan CP, Dawson JD, Reisinger HS, Singh H, Herwaldt LA. Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study. Crit Care Med 2023; 51:1492-1501. [PMID: 37246919 PMCID: PMC10615661 DOI: 10.1097/ccm.0000000000005942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
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.
Collapse
Affiliation(s)
- Christina L. Cifra
- Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Division of Medical Critical Care, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason W. Custer
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Craig M. Smith
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kristen A. Smith
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Dayanand N. Bagdure
- Department of Pediatrics, Louisiana State University Health Shreveport School of Medicine, Shreveport, Louisiana
| | - Jodi Bloxham
- University of Iowa College of Nursing, Iowa City, Iowa
| | - Emily Goldhar
- Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Stephen M. Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Elizabeth M. Hoppe
- Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Christina D. Miller
- Department of Pediatrics, Section of Critical Care, University of Colorado School of Medicine, Aurora, Colorado
| | - Max Pizzo
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Sonali Ramesh
- Department of Pediatrics, BronxCare Health System, New York, New York
| | - Joseph Riffe
- Department of Pediatrics, Family First Health, York, Pennsylvania
| | - Katharine Robb
- Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Shari L. Simone
- University of Maryland School of Nursing, Baltimore, Maryland
| | | | - Jamie Ann Tumulty
- Pediatric Intensive Care Unit, University of Maryland Children’s Hospital, Baltimore, Maryland
| | - Stephanie E. Wall
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Katie K. Wolfe
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Linder Wendt
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
| | - Patrick Ten Eyck
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey D. Dawson
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa
| | - Heather Schacht Reisinger
- University of Iowa Institute for Clinical and Translational Science, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Loreen A. Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| |
Collapse
|
3
|
Ladell MM, Shafer G, Ziniel SI, Grubenhoff JA. Comparative Perspectives on Diagnostic Error Discussions Between Inpatient and Outpatient Pediatric Providers. Am J Med Qual 2023; 38:245-254. [PMID: 37678302 PMCID: PMC10484186 DOI: 10.1097/jmq.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Diagnostic error remains understudied and underaddressed despite causing significant morbidity and mortality. One barrier to addressing this issue remains provider discomfort. Survey studies have shown significantly more discomfort among providers in discussing diagnostic error compared with other forms of error. Whether the comfort in discussing diagnostic error differs depending on practice setting has not been previously studied. The objective of this study was to assess differences in provider willingness to discuss diagnostic error in the inpatient versus outpatient setting. A multicenter survey was sent out to 3881 providers between May and June 2018. This survey was designed to assess comfort level of discussing diagnostic error and looking at barriers to discussing diagnostic error. Forty-three percent versus 22% of inpatient versus outpatient providers (P = 0.004) were comfortable discussing short-term diagnostic error publicly. Similarly, 76% versus 60% of inpatient versus outpatient providers (P = 0.010) were comfortable discussing short-term diagnostic error privately. A higher percentage of inpatient (64%) compared with outpatient providers (46%) (P = 0.043) were comfortable discussing long-term diagnostic error privately. Forty percent versus 24% of inpatient versus outpatient providers (P = 0.018) were comfortable discussing long-term error publicly. No difference in barriers cited depending on practice setting. Inpatient providers are more comfortable discussing diagnostic error than their outpatient counterparts. More study is needed to determine the etiology of this discrepancy and to develop strategies to increase outpatient provider comfort.
Collapse
Affiliation(s)
- Meagan M. Ladell
- Department of Pediatric (Section of Emergency Medicine), Children’s Wisconsin and Medical College of Wisconsin, Milwaukee, WI
| | - Grant Shafer
- Department of Pediatrics (Section of Neonatology), Children’s Hospital of Orange County and University of California Irvine, Orange, CA
| | - Sonja I. Ziniel
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Joseph A. Grubenhoff
- Department of Pediatrics (Section of Emergency Medicine), University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| |
Collapse
|
4
|
Congdon M, Rauch B, Carroll B, Costello A, Chua WD, Fairchild V, Fatemi Y, Greenfield ME, Herchline D, Howard A, Khan A, Lamberton CE, McAndrew L, Hart J, Shaw KN, Rasooly IR. Opportunities for Diagnostic Improvement Among Pediatric Hospital Readmissions. Hosp Pediatr 2023; 13:563-571. [PMID: 37271791 PMCID: PMC10330757 DOI: 10.1542/hpeds.2023-007157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Diagnostic errors, termed "missed opportunities for improving diagnosis" (MOIDs), are known sources of harm in children but have not been well characterized in pediatric hospital medicine. Our objectives were to systematically identify and describe MOIDs among general pediatric patients who experienced hospital readmission, outline improvement opportunities, and explore factors associated with increased risk of MOID. PATIENTS AND METHODS Our retrospective cohort study included unplanned readmissions within 15 days of discharge from a freestanding children's hospital (October 2018-September 2020). Health records from index admissions and readmissions were independently reviewed and discussed by practicing inpatient physicians to identify MOIDs using an established instrument, SaferDx. MOIDs were evaluated using a diagnostic-specific tool to identify improvement opportunities within the diagnostic process. RESULTS MOIDs were identified in 22 (6.3%) of 348 readmissions. Opportunities for improvement included: delay in considering the correct diagnosis (n = 11, 50%) and failure to order needed test(s) (n = 10, 45%). Patients with MOIDs were older (median age: 3.8 [interquartile range 1.5-11.2] vs 1.0 [0.3-4.9] years) than patients without MOIDs but similar in sex, primary language, race, ethnicity, and insurance type. We did not identify conditions associated with higher risk of MOID. Lower respiratory tract infections accounted for 26% of admission diagnoses but only 1 (4.5%) case of MOID. CONCLUSIONS Standardized review of pediatric readmissions identified MOIDs and opportunities for improvement within the diagnostic process, particularly in clinician decision-making. We identified conditions with low incidence of MOID. Further work is needed to better understand pediatric populations at highest risk for MOID.
Collapse
Affiliation(s)
- Morgan Congdon
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Bridget Rauch
- Center for Healthcare Quality and Analytics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
| | - Bryn Carroll
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Anna Costello
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Winona D. Chua
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Victoria Fairchild
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
| | - Yasaman Fatemi
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
| | - Morgan E. Greenfield
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Daniel Herchline
- Division of General Pediatrics, Cincinnati Children’s Hospital Medical Center
| | - Alexandra Howard
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Amina Khan
- Center for Healthcare Quality and Analytics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania 19104 US
| | - Courtney E. Lamberton
- Division of Critical Care Medicine, Hospital of the University of Pennsylvania and Pennsylvania Presbyterian Medical Center, Philadelphia, Pennsylvania 19104 USA
| | - Lisa McAndrew
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Jessica Hart
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Kathy N. Shaw
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
| | - Irit R. Rasooly
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, Pennsylvania 19104 USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, Pennsylvania, 19104 USA
- Department of Biomedical & Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania 19104 US
- Center for Pediatric Clinical Effectiveness & PolicyLab, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, 10th floor, Philadelphia, Pennsylvania, 19146 USA
| |
Collapse
|
5
|
Ribeiro MP, Duarte-Neto AN, Dolhnikoff M, Lindoso L, Lourenço B, Marques HH, Pereira MFB, Cristofani LM, Odone-Filho V, Campos LMA, Sallum AME, Carneiro-Sampaio M, Delgado AF, Carvalho WB, Mauad T, Silva CA. Major discrepancy between clinical diagnosis of death and anatomopathological findings in adolescents with chronic diseases during 18-years. Clinics (Sao Paulo) 2023; 78:100184. [PMID: 36972631 PMCID: PMC10091384 DOI: 10.1016/j.clinsp.2023.100184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 01/22/2023] [Accepted: 03/02/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVES To evaluate the inconsistency between clinical diagnosis of death and autopsy findings in adolescents with chronic diseases. METHODS A cross-sectional study including a sample of adolescents' autopsies who died in a pediatric and adolescent tertiary hospital over 18 consecutive years. During this period, there were n = 2912 deaths, and n = 581/2912(20%) occurred in adolescents. Of these, n = 85/581(15%) underwent autopsies and were analyzed. Further results were divided into two groups: Goldman classes I or II (high disagreement between main clinical diagnosis of death and anatomopathological findings, n = 26) and Goldman classes III, IV or V (low or no disagreement between these two parameters, n = 59). RESULTS Median age at death (13.5 [10‒19] vs. 13 [10‒19] years, p = 0.495) and disease duration (22 [0‒164] vs. 20 [0‒200] months, p = 0.931), and frequencies for males (58% vs. 44%, p = 0.247) were similar between class I/II vs. class III/IV/V. The frequency of pneumonia (73% vs. 48%, p = 0.029), pulmonary abscess (12% vs. 0%, p = 0.026), as well as isolation of yeast (27% vs. 5%, p = 0.008), and virus (15% vs. 2%, p = 0.029) identified in the autopsy, were significantly higher in adolescents with Goldman class I/II compared to those with Goldman class III/IV/V. In contrast, cerebral edema was significantly lower in adolescents of the first group (4% vs. 25%, p = 0.018). CONCLUSION This study showed that 30% of the adolescents with chronic diseases had major discrepancies between clinical diagnosis of death and autopsy findings. Pneumonia, pulmonary abscess, as well as isolation of yeast and virus were more frequently identified at autopsy findings in the groups with major discrepancies.
Collapse
Affiliation(s)
- Maira P Ribeiro
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Amaro N Duarte-Neto
- Patology Department, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Marisa Dolhnikoff
- Patology Department, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Livia Lindoso
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Benito Lourenço
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Heloisa H Marques
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Maria F B Pereira
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Lilian M Cristofani
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Vicente Odone-Filho
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Lucia M A Campos
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Adriana M E Sallum
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Magda Carneiro-Sampaio
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Artur F Delgado
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Werther B Carvalho
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Thais Mauad
- Patology Department, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Clovis A Silva
- Child and Adolescent Institute, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (HCFMUSP), São Paulo, SP, Brazil
| |
Collapse
|
6
|
Tewfik G, Srinivasan N, Rodriguez-Correa D, Tenorio C. A Survey-Based Assessment of the Practices Governing Morbidity and Mortality Conferences and the Effects of the COVID-19 Pandemic. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2022; 13:1515-1523. [PMID: 36568881 PMCID: PMC9788697 DOI: 10.2147/amep.s392653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/11/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Morbidity and mortality (M&M) conferences are essential components for resident education and provide a valuable tool to improve patient safety and quality of care. M&M conferences help identify important gaps in safety and reduce avoidable events in future patient care. Active methods to improve the utilization of M&M conferences have been shown to enhance their educational value for residents, faculty and multidisciplinary teams in healthcare institutions. OBJECTIVE The purpose of this study was to use a survey-based methodology to assess how morbidity and mortality conferences are conducted in residency programs, including characteristics such as frequency, involvement of personnel and the effects of COVID-19. METHODS From February to October 2021, a validated 19 question survey was electronically distributed to residency program directors in anesthesiology, emergency medicine and general surgery, after a search for email addresses in the ACGME database. The survey was created and hosted on Google Forms. RESULTS A total of 125 of 713 program directors (17.5%) responded to the survey. Eighty-three percent of respondent programs reported mandatory participation for residents, with residents providing most of the presentations. Case presentations utilized various formats including SBAR, adverse event analysis and root cause analysis as the most common modalities. Though most programs reported no change in frequency of M&M conferences due to COVID-19, most respondents reported a shift to a virtual or hybrid platform. CONCLUSION M&M conferences are an important educational and quality improvement modality, and many residency directors changed practice to incorporate virtual platforms due to the COVID-19 pandemic to maintain uninterrupted educational sessions. Nonetheless, significant variation still exists in how these conferences are conducted between different institutions.
Collapse
Affiliation(s)
- George Tewfik
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Nivetha Srinivasan
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Christopher Tenorio
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| |
Collapse
|
7
|
Joseph MM, Mahajan P, Snow SK, Ku BC, Saidinejad M. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics 2022; 150:189658. [PMID: 36189487 DOI: 10.1542/peds.2022-059674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 02/25/2023] Open
Abstract
Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.
Collapse
Affiliation(s)
- Madeline M Joseph
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, University of Florida Health Sciences Center-Jacksonville, Jacksonville, Florida
| | - Prashant Mahajan
- Departments of Pediatrics and Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Sally K Snow
- Independent Consultant in Pediatric Emergency and Trauma Nursing; Graham, Texas
| | - Brandon C Ku
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mohsen Saidinejad
- The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | | |
Collapse
|
8
|
Ramesh S, Ayres B, Eyck PT, Dawson JD, Reisinger HS, Singh H, Herwaldt LA, Cifra CL. Impact of subspecialty consultations on diagnosis in the pediatric intensive care unit. Diagnosis (Berl) 2022; 9:379-384. [PMID: 35393849 PMCID: PMC9427695 DOI: 10.1515/dx-2021-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/08/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Intensivists and subspecialists often collaborate in diagnosing patients in the pediatric intensive care unit (PICU). Our objectives were to characterize critically ill children for whom subspecialty consultations were requested, describe consultation characteristics, and determine consultations' impact on PICU diagnosis. METHODS We performed a retrospective study using chart review in a single tertiary referral PICU including children admitted for acute illness. We collected data on patients with and without subspecialty consultations within the first three days of PICU admission and determined changes in PICU clinicians' diagnostic evaluation or treatment after consultations. RESULTS PICU clinicians requested 152 subspecialty consultations for 87 of 101 (86%) patients. Consultations were requested equally for assistance in diagnosis (65%) and treatment (66%). Eighteen of 87 (21%) patients with consultations had a change in diagnosis from PICU admission to discharge, 11 (61%) attributed to subspecialty input. Thirty-nine (45%) patients with consultations had additional imaging and/or laboratory testing and 48 (55%) had medication changes and/or a procedure performed immediately after consultation. CONCLUSIONS Subspecialty consultations were requested during a majority of PICU admissions. Consultations can influence the diagnosis and treatment of critically ill children. Future research should investigate PICU interdisciplinary collaborations, which are essential for teamwork in diagnosis.
Collapse
Affiliation(s)
- Sonali Ramesh
- Department of Pediatrics, BronxCare Health System, New York, NY, USA
| | - Brennan Ayres
- Touro College of Osteopathic Medicine, New York, NY, USA
| | - Patrick Ten Eyck
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, USA.,Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Jeffrey D Dawson
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Heather Schacht Reisinger
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA, USA.,Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Loreen A Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.,Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Christina L Cifra
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| |
Collapse
|
9
|
Cifra CL, Custer JW, Fackler JC. A Research Agenda for Diagnostic Excellence in Critical Care Medicine. Crit Care Clin 2022; 38:141-157. [PMID: 34794628 PMCID: PMC8963385 DOI: 10.1016/j.ccc.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Diagnosing critically ill patients in the intensive care unit is difficult. As a result, diagnostic errors in the intensive care unit are common and have been shown to cause harm. Research to improve diagnosis in critical care medicine has accelerated in past years. However, much work remains to fully elucidate the diagnostic process in critical care. To achieve diagnostic excellence, interdisciplinary research is needed, adopting a balanced strategy of continued biomedical discovery while addressing the complex care delivery systems underpinning the diagnosis of critical illness.
Collapse
|
10
|
Sawicki JG, Nystrom D, Purtell R, Good B, Chaulk D. Diagnostic error in the pediatric hospital: a narrative review. Hosp Pract (1995) 2021; 49:437-444. [PMID: 34743667 DOI: 10.1080/21548331.2021.2004040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Diagnostic error is a prevalent type of medical error that is associated with considerable patient harm and increased medical costs. The majority of literature guiding the current understanding of diagnostic error in the hospital setting is from adult studies. However, there is research to suggest this type of error is also prevalent in the pediatric specialty. OBJECTIVES The primary objective of this study was to define the current understanding of diagnostic error in the pediatric hospital through a structured literature review. METHODS We searched PubMed and identified studies focusing on three aspects of diagnostic error in pediatric hospitals: the incidence or prevalence, contributing factors, and related interventions. We used a tiered review, and a standardized electronic form to extract data from included articles. RESULTS Fifty-nine abstracts were screened and 23 full-text studies were included in the final review. Seventeen of the 23 studies focused on the incidence or prevalence, with only 3 studies investigating the utility of interventions. Most studies took place in an intensive care unit or emergency department with very few studies including only patients on the general wards. Overall, the prevalence of diagnostic error in pediatric hospitals varied greatly and depended on the measurement technique and specific hospital setting. Both healthcare system factors and individual cognitive factors were found to contribute to diagnostic error, with there being limited evidence to guide how best to mitigate the influence of these factors on the diagnostic process. CONCLUSION The general knowledge of diagnostic error in pediatric hospital settings is limited. Future work should incorporate structured frameworks to measure diagnostic errors and examine clinicians' diagnostic processes in real-time to help guide effective hospital-wide interventions.
Collapse
Affiliation(s)
- Jonathan G Sawicki
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daniel Nystrom
- Clinical Risk Management, Intermountain Healthcare, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Rebecca Purtell
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Brian Good
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David Chaulk
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| |
Collapse
|
11
|
Shafer G, Gautham KS. Diagnostic Error: Why Now? Crit Care Clin 2021; 38:1-10. [PMID: 34794623 DOI: 10.1016/j.ccc.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diagnostic errors remain relatively understudied and underappreciated. They are particularly concerning in the intensive care unit, where they are more likely to result in harm to patients. There is a lack of consensus on the definition of diagnostic error, and current methods to quantify diagnostic error have numerous limitations as noted in the sentinel report by the National Academy of Medicine. Although definitive definition and measurement remain elusive goals, increasing our understanding of diagnostic error is crucial if we are to make progress in reducing the incidence and harm caused by errors in diagnosis.
Collapse
Affiliation(s)
- Grant Shafer
- Division of Neonatology, Children's Hospital of Orange County, 1201 West La Veta Avenue, Orange, CA 92868, USA.
| | | |
Collapse
|
12
|
Stocker M, Szavay P, Wernz B, Neuhaus TJ, Lehnick D, Zundel S. What are the participants' perspective and the system-based impact of a standardized, inter-professional morbidity/mortality-conferences in a children's hospital? Transl Gastroenterol Hepatol 2021; 6:48. [PMID: 34423169 DOI: 10.21037/tgh-20-42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/20/2020] [Indexed: 11/06/2022] Open
Abstract
Background Morbidity and mortality conferences (MMC) are well established but little data exists on inter-professional aspects, system-based outcomes and characteristics in pediatric departments. Our study aim was to analyze the system-based impact and to assess participant's perspectives on standardized, inter-professional MMCs in a children's hospital. Methods In a prospective observational analysis the inter-professional MMCs held at a tertiary teaching children's hospital in Switzerland were analyzed for (I) resulting clinical consequences and (II) participants perception on format, usefulness and no-blame atmosphere. Results Eighteen MMC, discussing 29 cases were analyzed. Twenty-seven clinical errors/problems were identified and 17 clinical recommendations were developed: ten new or changed clinical guidelines, two new therapeutic alternatives, three new teaching activities, and two guidelines on specific diagnostics. Altogether, the 466 participants evaluated the conferences favorably. Little differences were seen in the evaluations of physicians of different disciplines or seniority but non-physicians scored all questions lower than physicians. Overall, three quarters of the participants felt that there was a no-blame culture during the conferences but results varied depending on the cases discussed. Conclusions An inter-professional MMC can have relevant impact on clinical practice and affect system-based changes. Inter-professional conferences are profitable for all participants but evaluated differently according to profession. A standardized format and the presence of a moderator are helpful, but not a guarantee for a no-blame culture. Highly emotional cases are a risk factor to relapse to "blame and shame". A time gap between the event and the MMC may have a beneficial effect. Keywords Inter-professional communication; inter-professional health care; learning from failure; morbidity and mortality conference (MMC); patient safety; psychological safety.
Collapse
Affiliation(s)
- Martin Stocker
- Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Luzern, Switzerland.,Department of Pediatrics, Children's Hospital Lucerne, Luzern, Switzerland
| | - Philipp Szavay
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzern, Switzerland
| | - Birgit Wernz
- Department of Nursing, Children's Hospital Lucerne, Luzern, Switzerland
| | - Thomas J Neuhaus
- Department of Pediatrics, Children's Hospital Lucerne, Luzern, Switzerland
| | - Dirk Lehnick
- Biostatistics and Methodology, University of Lucerne, Luzern, Switzerland
| | - Sabine Zundel
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzern, Switzerland
| |
Collapse
|
13
|
Abstract
OBJECTIVES To summarize the literature on prevalence, impact, and contributing factors related to diagnostic error in the PICU. DATA SOURCES Search of PubMed, EMBASE, and the Cochrane Library up to December 2019. STUDY SELECTION Studies on diagnostic error and the diagnostic process in pediatric critical care were included. Non-English studies with no translation, case reports/series, studies providing no information on diagnostic error, studies focused on non-PICU populations, and studies focused on a single condition/disease or a single diagnostic test/tool were excluded. DATA EXTRACTION Data on research design, objectives, study sample, and results pertaining to the prevalence, impact, and factors associated with diagnostic error were abstracted from each study. DATA SYNTHESIS Using independent tiered review, 396 abstracts were screened, and 17 studies (14 full-text, 3 abstracts) were ultimately included. Fifteen of 17 studies (88%) had an observational research design. Autopsy studies (autopsy rates were 20-47%) showed a 10-23% rate of missed major diagnoses; 5-16% of autopsy-discovered diagnostic errors had a potential adverse impact on survival and would have changed management. Retrospective record reviews reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions and 21-25% of patients discussed at PICU morbidity and mortality conferences. Cardiovascular, infectious, congenital, and neurologic conditions were most commonly misdiagnosed. Systems factors (40-67%), cognitive factors (20-3%), and both systems and cognitive factors (40%) were associated with diagnostic error. Limited information was available on the impact of misdiagnosis. CONCLUSIONS Knowledge of diagnostic errors in the PICU is limited. Future work to understand diagnostic errors should involve a balanced focus between studying the diagnosis of individual diseases and uncovering common system- and process-related determinants of diagnostic error.
Collapse
Affiliation(s)
- Christina L. Cifra
- Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Jason W. Custer
- Division of Critical Care, Department of Pediatrics, University of Maryland, Baltimore, Maryland
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - James C. Fackler
- Division of Pediatric Anesthesia and Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| |
Collapse
|
14
|
Cifra CL, Dukes KC, Ayres BS, Calomino KA, Herwaldt LA, Singh H, Reisinger HS. Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: A pilot ethnography. J Crit Care 2020; 63:246-249. [PMID: 32980235 DOI: 10.1016/j.jcrc.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/27/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The effect of communication between referring and accepting clinicians during patient transitions to the pediatric intensive care unit (PICU) on diagnostic quality is largely unknown. This pilot study aims to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children. MATERIALS AND METHODS We conducted focused ethnography in an academic tertiary referral PICU by directly observing the referral and admission of 3 non-electively admitted children 0-17 years old. We also conducted 21 semi-structured interviews of their parents and admitting PICU staff (intensivists, fellows/residents, medical students, nurses, and respiratory therapists) and reviewed their medical records post-discharge. RESULTS Performing focused ethnography in a busy PICU is feasible. We identified three areas for additional exploration: (1) how information transfer affects the PICU diagnostic process; (2) how uncertainty in patient assessment affects the decision to transfer to the PICU; and (3) how the PICU team's expectations are influenced by referral communication. CONCLUSIONS Focused ethnography in the PICU is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children.
Collapse
Affiliation(s)
- Christina L Cifra
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, 200 Hawkins Dr 8600-M JCP, Iowa City, IA 52242, USA.
| | - Kimberly C Dukes
- Institute for Clinical and Translational Science, University of Iowa 200 Hawkins Dr, Iowa City, IA 52242, USA; Iowa City Veterans Affairs Health Care System, 601 US-6 W Suite 42-1 VAMC, Iowa City, IA 52246, USA.
| | - Brennan S Ayres
- Department of Industrial and Systems Engineering, University of Iowa College of Engineering 3100 Seamans Center for the Engineering Arts and Sciences, Iowa City, IA 52242, USA; Touro College of Osteopathic Medicine (present address), 230 W 125(th) St, New York, NY 10027, USA
| | - Kelsey A Calomino
- University of Iowa College of Nursing, 50 Newton Rd, Iowa City, IA 52242, USA.
| | - Loreen A Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine 200 Hawkins Dr, Iowa City, IA 52242, USA; Department of Epidemiology, University of Iowa College of Public Health 145 N Riverside Dr, Iowa City, IA 52242, USA.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey eterans Affairs Medical Center and Baylor College of Medicine, 2002 Holcombe Blvd, Houston, TX 77030, USA.
| | - Heather Schacht Reisinger
- Institute for Clinical and Translational Science, University of Iowa 200 Hawkins Dr, Iowa City, IA 52242, USA; Department of Internal Medicine, University of Iowa Carver College of Medicine 200 Hawkins Dr, Iowa City, IA 52242, USA; Iowa City Veterans Affairs Health Care System, 601 US-6 W Suite 42-1 VAMC, Iowa City, IA 52246, USA.
| |
Collapse
|
15
|
Singh H, Bradford A, Goeschel C. Operational measurement of diagnostic safety: state of the science. ACTA ACUST UNITED AC 2020; 8:51-65. [PMID: 32706749 DOI: 10.1515/dx-2020-0045] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/18/2020] [Indexed: 12/15/2022]
Abstract
Reducing the incidence of diagnostic errors is increasingly a priority for government, professional, and philanthropic organizations. Several obstacles to measurement of diagnostic safety have hampered progress toward this goal. Although a coordinated national strategy to measure diagnostic safety remains an aspirational goal, recent research has yielded practical guidance for healthcare organizations to start using measurement to enhance diagnostic safety. This paper, concurrently published as an Issue Brief by the Agency for Healthcare Research and Quality, issues a "call to action" for healthcare organizations to begin measurement efforts using data sources currently available to them. Our aims are to outline the state of the science and provide practical recommendations for organizations to start identifying and learning from diagnostic errors. Whether by strategically leveraging current resources or building additional capacity for data gathering, nearly all organizations can begin their journeys to measure and reduce preventable diagnostic harm.
Collapse
Affiliation(s)
- Hardeep Singh
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Baylor College of Medicine, 2002 Holcombe Blvd. #152, Houston, TX, USA
| | - Andrea Bradford
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christine Goeschel
- MedStar Health Institute for Quality and Safety, MD, USA
- Department of Medicine, Georgetown University, Washington, DC, USA
| |
Collapse
|
16
|
Abstract
OBJECTIVES Diagnostic errors can harm critically ill children. However, we know little about their prevalence in PICUs and factors associated with error. The objective of this pilot study was to determine feasibility of record review to identify patient, provider, and work system factors associated with diagnostic errors during the first 12 hours after PICU admission. DESIGN Pilot retrospective cohort study with structured record review using a structured tool (Safer Dx instrument) to identify diagnostic error. SETTING Academic tertiary referral PICU. PATIENTS Patients 0-17 years old admitted nonelectively to the PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four of 50 patients (8%) had diagnostic errors in the first 12 hours after admission. The Safer Dx instrument helped identify delayed diagnoses of chronic ear infection, increased intracranial pressure (two cases), and Bartonella encephalitis. We calculated that 610 PICU admissions are needed to achieve 80% power (α = 0.05) to detect significant associations with error. CONCLUSIONS Our pilot study found four patients with diagnostic error out of 50 children admitted nonelectively to a PICU. Retrospective record review using a structured tool to identify diagnostic errors is feasible in this population. Pilot data are being used to inform a larger and more definitive multicenter study.
Collapse
|
17
|
Abbas Q, Memon F, Laghari P, Saleem A, Haque A. Potentially Preventable Mortality in the Pediatric Intensive Care Unit: Findings from a Retrospective Mortality Analysis. Cureus 2020; 12:e7358. [PMID: 32328370 PMCID: PMC7174862 DOI: 10.7759/cureus.7358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective The goal of this study was to estimate the proportion and causes of potentially preventable mortality among critically ill children admitted to the pediatric intensive care unit (PICU). Methods The medical records of all patients who died in the PICU (age range: one month to 16 years) between January 2014 and December 2015 were evaluated by two independent reviewers to determine whether there had been any delayed recognition of deteriorating conditions, delayed interventions, unintentional/unanticipated harm, medication errors, adverse reactions to transfusions, and hospital-acquired infections that could have resulted in unanticipated death. Preventability was labeled on a 6-point scale. Results During the study period, 92 of 690 patients did not survive [median age: 60 months, interquartile range (IQR): 114]. The median Pediatric Risk of Mortality (PRISM) III score was 17 (IQR: 6). Major diagnostic categories included sepsis (n = 29, 35%), central nervous system diseases (n = 16, 17%), oncological/hematological diseases (n = 6, 6%), cardiac diseases (n = 4, 4%), and miscellaneous conditions. None of the deaths had definitive or strong evidence of preventability. Four (4.3%) patients were in category 4 (i.e., possibly preventable, >50/50 chance), 15 (16.3%) in category 3 (possibly preventable, <50/50 chance), 28 (30.4%) had some evidence of preventability, and 45 (49.0%) were labeled as definitely not preventable. Late identification (diagnostic error) of the worsening condition in four (21.0%) patients, slow intervention in six (31.6.0%), and hospital-acquired infections in 10 (52.6%) were found to be related to potentially preventable mortality. Conclusions Preventable diagnostic errors and nosocomial infections (NIs) are major contributors to preventable mortality. Structured mortality analysis provides actionable information for future preventive strategies. Improvement in care processes, including clinical decision support systems, could help reduce preventable mortality rates.
Collapse
Affiliation(s)
- Qalab Abbas
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, PAK
| | - Fozia Memon
- Pediatrics, Aga Khan University Hospital, Karachi, PAK
| | | | - Ali Saleem
- Pediatrics, Aga Khan University Hospital, Karachi, PAK
| | - Anwar Haque
- Pediatrics, The Indus Hospital, Karachi, PAK
| |
Collapse
|
18
|
Diagnostic Error in the Critically III: Defining the Problem and Exploring Next Steps to Advance Intensive Care Unit Safety. Ann Am Thorac Soc 2019; 15:903-907. [PMID: 29742359 DOI: 10.1513/annalsats.201801-068ps] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
19
|
If You're HAPI and You Know It, Do No Harm. Pediatr Crit Care Med 2019; 20:1093-1094. [PMID: 31688681 DOI: 10.1097/pcc.0000000000002089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
20
|
Jayaprakash N, Chae J, Sabov M, Samavedam S, Gajic O, Pickering BW. Improving Diagnostic Fidelity: An Approach to Standardizing the Process in Patients With Emerging Critical Illness. Mayo Clin Proc Innov Qual Outcomes 2019; 3:327-334. [PMID: 31485571 PMCID: PMC6713917 DOI: 10.1016/j.mayocpiqo.2019.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/11/2019] [Accepted: 06/10/2019] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE To reliably improve diagnostic fidelity and identify delays using a standardized approach applied to the electronic medical records of patients with emerging critical illness. PATIENTS AND METHODS This retrospective observational study at Mayo Clinic, Rochester, Minnesota, conducted June 1, 2016, to June 30, 2017, used a standard operating procedure applied to electronic medical records to identify variations in diagnostic fidelity and/or delay in adult patients with a rapid response team evaluation, at risk for critical illness. Multivariate logistic regression analysis identified predictors and compared outcomes for those with and without varying diagnostic fidelity and/or delay. RESULTS The sample included 130 patients. Median age was 65 years (interquartile range, 56-76 years), and 47.0% (52 of 130) were women. Clinically significant diagnostic error or delay was agreed in 23 (17.7%) patients (κ=0.57; 95% CI, 0.40-0.74). Median age was 65.4 years (interquartile range, 60.3-74.8) and 9 of the 23 (30.1%) were female. Of those with diagnostic error or delay, 60.9% (14 of 23) died in the hospital compared with 19.6% (21 of 107) without; P<.001. Diagnostic error or delay was associated with higher Charlson comorbidity index score, cardiac arrest triage score, and do not intubate/do not resuscitate status. Adjusting for age, do not intubate/do not resuscitate status, and Charlson comorbidity index score, diagnostic error or delay was associated with increased mortality; odds ratio, 5.7; 95% CI, 2.0-17.8. CONCLUSION Diagnostic errors or delays can be reliably identified and are associated with higher comorbidity burden and increased mortality.
Collapse
Affiliation(s)
- Namita Jayaprakash
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
- Division of Pulmonary and Critical Care, Henry Ford Hospital, Detroit, MI
| | - Junemee Chae
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Moldovan Sabov
- Department of Internal Medicine, Canton Medical Education Foundation, Canton, OH
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
21
|
Grubenhoff JA, Ziniel SI, Bajaj L, Hyman D. Pediatric faculty knowledge and comfort discussing diagnostic errors: a pilot survey to understand barriers to an educational program. Diagnosis (Berl) 2019; 6:101-107. [DOI: 10.1515/dx-2018-0056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 01/21/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Improving Diagnosis in Healthcare calls for improved training in diagnostic reasoning and establishing non-judgmental forums to learn from diagnostic errors arising from heuristic-driven reasoning. Little is known about pediatric providers’ familiarity with heuristics or the culture surrounding forums where diagnostic errors are discussed. This study aimed to describe pediatric providers’ familiarity with common heuristics and perceptions surrounding public discussions of diagnostic errors.
Methods
We surveyed pediatric providers at a university-affiliated children’s hospital. The survey asked participants to identify common heuristics used during clinical reasoning (five definitions; four exemplar clinical vignettes). Participants answered questions regarding comfort publicly discussing their own diagnostic errors and barriers to sharing them.
Results
Seventy (30.6% response rate) faculty completed the survey. The mean number of correctly selected heuristics was 1.60/5 [standard deviation (SD)=1.13] and 1.01/4 (SD=1.06) for the definitions and vignettes, respectively. A low but significant correlation existed between correctly identifying a definition and selecting the correct heuristic in vignettes (Spearman’s ρ=0.27, p=0.02). Clinicians were significantly less likely to be “pretty” or “very” comfortable discussing diagnostic errors in public vs. private conversations (28.3% vs. 74.3%, p<0.01). The most frequently cited barriers to discussing errors were loss of reputation (62.9%) and fear of knowledge-base (58.6%) or decision-making (57.1%) being judged.
Conclusions
Pediatric providers demonstrated limited familiarity with common heuristics leading to diagnostic error. Greater years in practice is associated with more comfort discussing diagnostic errors, but negative peer and personal perceptions of diagnostic performance are common barriers to discussing errors publicly.
Collapse
Affiliation(s)
- Joseph A. Grubenhoff
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Sonja I. Ziniel
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Lalit Bajaj
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| | - Daniel Hyman
- University of Colorado Denver School of Medicine , Aurora, CO , USA
- Children’s Hospital Colorado , Aurora, CO , USA
| |
Collapse
|
22
|
Chu D, Xiao J, Shah P, Todd B. How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences? Diagnosis (Berl) 2018; 5:143-150. [PMID: 29924736 DOI: 10.1515/dx-2017-0046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 05/23/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Cognitive errors are a major contributor to medical error. Traditionally, medical errors at teaching hospitals are analyzed in morbidity and mortality (M&M) conferences. We aimed to describe the frequency of cognitive errors in relation to the occurrence of diagnostic and other error types, in cases presented at an emergency medicine (EM) resident M&M conference.
Methods
We conducted a retrospective study of all cases presented at a suburban US EM residency monthly M&M conference from September 2011 to August 2016. Each case was reviewed using the electronic medical record (EMR) and notes from the M&M case by two EM physicians. Each case was categorized by type of primary medical error that occurred as described by Okafor et al. When a diagnostic error occurred, the case was reviewed for contributing cognitive and non-cognitive factors. Finally, when a cognitive error occurred, the case was classified into faulty knowledge, faulty data gathering or faulty synthesis, as described by Graber et al. Disagreements in error type were mediated by a third EM physician.
Results
A total of 87 M&M cases were reviewed; the two reviewers agreed on 73 cases, and 14 cases required mediation by a third reviewer. Forty-eight cases involved diagnostic errors, 47 of which were cognitive errors. Of these 47 cases, 38 involved faulty synthesis, 22 involved faulty data gathering and only 11 involved faulty knowledge. Twenty cases contained more than one type of cognitive error. Twenty-nine cases involved both a resident and an attending physician, while 17 cases involved only an attending physician. Twenty-one percent of the resident cases involved all three cognitive errors, while none of the attending cases involved all three. Forty-one percent of the resident cases and only 6% of the attending cases involved faulty knowledge. One hundred percent of the resident cases and 94% of the attending cases involved faulty synthesis.
Conclusions
Our review of 87 EM M&M cases revealed that cognitive errors are commonly involved in cases presented, and that these errors are less likely due to deficient knowledge and more likely due to faulty synthesis. M&M conferences may therefore provide an excellent forum to discuss cognitive errors and how to reduce their occurrence.
Collapse
Affiliation(s)
- David Chu
- Oakland University William Beaumont School of Medicine, 3671 Crooks Rd. Apt. 3, Royal Oak, MI 48073, USA
| | - Jane Xiao
- Beaumont Health System, Emergency Medicine, Royal Oak, MI, USA
| | - Payal Shah
- Beaumont Health System, Emergency Medicine, Royal Oak, MI, USA
| | - Brett Todd
- Beaumont Health System, Emergency Medicine, Royal Oak, MI, USA
| |
Collapse
|
23
|
Murray DJ, Boyle WA, Beyatte MB, Knittel JG, Kerby PW, Woodhouse J, Boulet JR. Decision-making skills improve with critical care training: Using simulation to measure progress. J Crit Care 2018; 47:133-138. [PMID: 29981998 DOI: 10.1016/j.jcrc.2018.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/26/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Health care professionals are expected to acquire decision-making skills during their training, but few methods are available to assess progress in acquiring these essential skills. The purpose of this study was to determine whether a simulation methodology could be used to assess whether decision-making skills improve during critical care training. MATERIALS AND METHODS Sixteen simulated scenarios were designed to assess a critical care provider's ability to make decisions in the care of a critical ill patient. Seventeen (17) critical care providers managed 8 of the scenarios early during their training and then managed a second set of 8 scenarios (T2) at the conclusion of their training. RESULTS Provider's mean global scenario scores (0-9) increased significantly fromT1 and T2 (5.64 ± 0.74) and (6.54 ± 0.64) with a large effect size (1.3). Acute care nurse practitioners and fellows achieved similar overall scores at the conclusion of their training (ACNP 6.43 ± 0.57; Fellows 6.64 ± 0.72). CONCLUSIONS These findings provide evidence to support the validity of a simulation-based method to assess progress in decision-making skills. A simulation methodology could be used to establish a performance standard that determined a provider's ability to make independent decisions.
Collapse
Affiliation(s)
- David J Murray
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States of America; Howard and Joyce Wood Simulation Center, Washington University School of Medicine, St Louis, MO, United States of America.
| | - Walter A Boyle
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States of America; Critical Care Medicine Division, Department of lgnesthesiology, Washington University School of Medicine, St Louis, MO, United States of America
| | - Mary Beth Beyatte
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States of America; Critical Care Medicine Division, Department of lgnesthesiology, Washington University School of Medicine, St Louis, MO, United States of America; Goldfarb School of Nursing at Barnes-Jewish College, St Louis, MO, United States of America
| | - Justin G Knittel
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States of America; Critical Care Medicine Division, Department of lgnesthesiology, Washington University School of Medicine, St Louis, MO, United States of America
| | - Paul W Kerby
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States of America; Critical Care Medicine Division, Department of lgnesthesiology, Washington University School of Medicine, St Louis, MO, United States of America
| | - Julie Woodhouse
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, United States of America; Howard and Joyce Wood Simulation Center, Washington University School of Medicine, St Louis, MO, United States of America
| | - John R Boulet
- Foundation for Advancement of International Medical Education and Research, Philadelphia, PA, United States of America
| |
Collapse
|
24
|
Abstract
UNLABELLED IntroductionDiagnostic errors cause significant patient harm and increase costs. Data characterising such errors in the paediatric cardiac intensive care population are limited. We sought to understand the perceived frequency and types of diagnostic errors in the paediatric cardiac ICU. METHODS Paediatric cardiac ICU practitioners including attending and trainee physicians, nurse practitioners, physician assistants, and registered nurses at three North American tertiary cardiac centres were surveyed between October 2014 and January 2015. RESULTS The response rate was 46% (N=200). Most respondents (81%) perceived that diagnostic errors harm patients more than five times per year. More than half (65%) reported that errors permanently harm patients, and up to 18% perceived that diagnostic errors contributed to death or severe permanent harm more than five times per year. Medication side effects and psychiatric conditions were thought to be most commonly misdiagnosed. Physician groups also ranked pulmonary overcirculation and viral illness to be commonly misdiagnosed as bacterial illness. Inadequate care coordination, data assessment, and high clinician workload were cited as contributory factors. Delayed diagnostic studies and interventions related to the severity of the patient's condition were thought to be the most commonly reported process breakdowns. All surveyed groups ranked improving teamwork and feedback pathways as strategies to explore for preventing future diagnostic errors. CONCLUSIONS Paediatric cardiac intensive care practitioners perceive that diagnostic errors causing permanent harm are common and associated more with systematic and process breakdowns than with cognitive limitations.
Collapse
|
25
|
Gleason KT, Davidson PM, Tanner EK, Baptiste D, Rushton C, Day J, Sawyer M, Baker D, Paine L, Himmelfarb CRD, Newman-Toker DE. Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2017-0015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractNurses have always been involved in the diagnostic process, but there remains a pervasive view across physicians, nurses, and allied health professionals that medical diagnosis is solely a physician responsibility. There is an urgent need to adjust this view and for nurses to take part in leading efforts addressing diagnostic errors. The purpose of this article is to define a framework for nursing engagement in the diagnostic process that can serve as a catalyst for nurses to engage in eliminating preventable harms from diagnostic error. We offer a conceptual model to formalize and expand nurses’ engagement in the diagnostic process through education, maximize effectiveness of interprofessional teamwork and communication through culture change, and leverage the nursing mission to empower patients to become active members of the diagnostic team. We describe the primary barriers, including culture, education, operations, and regulations, to nurses participating as full, equal members of the diagnostic team, and illustrate our approach to addressing these barriers. Nurses already play a major role in diagnosis and increasingly take ownership of this role, removing barriers will strengthen nurses’ ability to be equal, integral diagnostic team members. This model should serve as a foundation for increasing the role of the nurse in the diagnostic process, and calling nurses to take action in leading efforts to reduce diagnostic error.
Collapse
|
26
|
Taking Aim at Diagnostic Errors. Pediatr Crit Care Med 2017; 18:285-286. [PMID: 28257370 DOI: 10.1097/pcc.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
27
|
Abstract
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.
Collapse
|
28
|
Widmann R, Caduff R, Giudici L, Zhong Q, Vogetseder A, Arlettaz R, Frey B, Moch H, Bode PK. Value of postmortem studies in deceased neonatal and pediatric intensive care unit patients. Virchows Arch 2016; 470:217-223. [DOI: 10.1007/s00428-016-2056-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/03/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
|
29
|
|
30
|
|
31
|
The authors reply. Pediatr Crit Care Med 2015; 16:896-7. [PMID: 26536561 DOI: 10.1097/pcc.0000000000000552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
32
|
To Err One's Dirty Laundry. Pediatr Crit Care Med 2015; 16:488-9. [PMID: 26039431 DOI: 10.1097/pcc.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|