- Half of diagnostic errors are reported to result in patient harm in pediatrics and comprise up to one-third of pediatric malpractice lawsuits. But the true incidence of diagnostic errors cannot be accurately estimated due to a significant challenge of having the resources to accurately identify them.
- Diagnostic errors are different than medical errors in that the exposure of interest is in the diagnostic encounter itself as opposed to more discrete events like central lines, falls, or surgery related errors.
- Another issue is that diagnostic errors that do not result in significant morbidity or mortality are under reported.
- With the advent of the electronic health record, automated electronic triggers may provide a solution to capture diagnostic errors, especially those that don’t result in significant harm. Specific to the peds ED, unscheduled return visits resulting in admission were determined to be a high priority for possible diagnostic detection using e-triggers combined with a detailed chart review. A diagnostic error in this study was defined as missed opportunities to make a correct or timely diagnosis with the information available.
- This was a retrospective chart review from a single academic pediatric Level 1 trauma and tertiary care center ED and five satellite EDs. Across all sites, there were approximately 165,000 patient ED visits per year with 7-8% admission rate. Patients aged 0-22 years old admitted within 14 days of a previous ED visit during the study period were eligible. An e-trigger algorithm was designed to extract data according to the study criteria. Then the e-triggered cases were screened by a pediatric ER physician or nurse to determine if the event represented a possible missed diagnostic opportunity using a scoring instrument (Revised SaferDx).
- Over the 2-year study period, the authors found 313,760 ED visits and 24,849 admissions from the ED. 7.7% of these admissions met e-trigger criteria occurring within 14 days of a prior ED visit with 1,462 cases deemed ineligible for detailed review. The remaining 453 cases underwent detailed chart review and 20.3% of the cases (92) were classified as likely diagnostic errors.
- The combination of an e-trigger application followed by clinician screening increased the proportion of diagnostic error identification resulting in admission. It went from 0.4% to 4.8% among cases meeting just the e-trigger criteria. This increased to 20.3% when the e-trigger was coupled with a reliable screening process.
- Over all these cases, the 5 most frequently missed diagnoses were musculoskeletal infection, intracranial mass/cavernous sinus thrombus, meningitis, sepsis, and appendicitis which suggests that faulty reasoning in the diagnostic process occurs frequently.
- Systemic surveillance can be more likely to reveal recurring factors or patient presentations that place patients at risk for a likely diagnostic error.
Summary of "Use of e-triggers to identify diagnostic errors in the paediatric ED"
Summary published October 12, 2022