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Finding Diagnostic Errors in Children Admitted to the PICU

Davalos, Maria Caridad MD; Samuels, Kenya MPAS, PA-C; Meyer, Ashley N. D. PhD; Thammasitboon, Satid MD, MHPE; Sur, Moushumi MD; Roy, Kevin MD; Al-Mutairi, Aymer MD; Singh, Hardeep MD, MPH

Pediatric Critical Care Medicine: March 2017 - Volume 18 - Issue 3 - p 265–271
doi: 10.1097/PCC.0000000000001059
Quality and Safety

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.

1Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX.

2Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX.

3Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX.

*See also p. 285.

Current affiliation for Dr. Davalos: Universidad San Francisco de Quito and Hospital Pediatrico Baca Ortiz, Quito. Ecuador.

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the U.S. government, Baylor College of Medicine or any other funding agency.

Dr. Singh is supported by the VA Health Services Research and Development Service (CRE 12–033; Presidential Early Career Award for Scientists and Engineers USA 14–274), the VA National Center for Patient Safety and the Agency for Health Care Research and Quality (R01HS022087), and the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413).

Dr. Meyer disclosed that he did government work. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: hardeeps@bcm.edu

©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies