Project RedDE: Cluster Randomized Trial to Reduce Missed or Delayed Abnormal Laboratory Value Actions

Diagnostic Error in Pediatrics: A Narrative Review

A priority topic for patient safety research is diagnostic errors. However, despite the significant growth in awareness of their unacceptably high incidence and associated harm, a relative paucity of large, high-quality studies of diagnostic error in pediatrics exists. In this narrative review, we present what is known about the incidence and epidemiology of diagnostic error in pediatrics as well as the established research methods for identifying, evaluating, and reducing diagnostic errors, including their strengths and weaknesses. Additionally, we highlight that pediatric diagnostic error remains an area in need of both innovative research and quality improvement efforts to apply learnings from a rapidly growing evidence base. We propose several key research questions aimed at addressing persistent gaps in the pediatric diagnostic error literature that focus on the foundational knowledge needed to inform effective interventions to reduce the incidence of diagnostic errors and their associated harm. Additional research is needed to better establish the epidemiology of diagnostic error in pediatrics, including identifying high-risk clinical scenarios, patient populations, and groups of diagnoses. A critical need exists for validated measures of both diagnostic errors and diagnostic processes that can be adapted for different clinical settings and standardized for use across varying institutions. Pediatric researchers will need to work collaboratively on large-scale, high-quality studies to accomplish the ultimate goal of reducing diagnostic errors and their associated harm in children by addressing these fundamental gaps in knowledge.

Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE

BACKGROUND

Pediatric ambulatory diagnostic errors (DEs) occur frequently. We used root cause analyses (RCAs) to identify their failure points and contributing factors.

METHODS

Thirty-one practices were enrolled in a national QI collaborative to reduce 3 DEs occurring at different stages of the diagnostic process: missed adolescent depression, missed elevated blood pressure (BP), and missed actionable laboratory values. Practices were encouraged to perform monthly "mini-RCAs" to identify failure points and prioritize interventions. Information related to process steps involved, specific contributing factors, and recommended interventions were reported monthly. Data were analyzed using descriptive statistics and Pareto charts.

RESULTS

Twenty-eight (90%) practices submitted 184 mini-RCAs. The median number of mini-RCAs submitted was 6 (interquartile range, 2-9). For missed adolescent depression, the process step most commonly identified was the failure to screen (68%). For missed elevated BP, it was the failure to recognize (36%) and act on (28%) abnormal BP. For missed actionable laboratories, failure to notify families (23%) and document actions on (19%) abnormal results were the process steps most commonly identified. Top contributing factors to missed adolescent depression included patient volume (16%) and inadequate staffing (13%). Top contributing factors to missed elevated BP included patient volume (12%), clinic milieu (9%), and electronic health records (EHRs) (8%). Top contributing factors to missed actionable laboratories included written communication (13%), EHR (9%), and provider knowledge (8%). Recommended interventions were similar across errors.

CONCLUSIONS

EHR-based interventions, standardization of processes, and cross-training may help decrease DEs in the pediatric ambulatory setting. Mini-RCAs are useful tools to identify their contributing factors and interventions.