Diagnostic Error in Pediatric Critical Care: A Multicenter Study
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Quality and Patient Safety, Worldwide Data, Pediatrics, 2022
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INTRODUCTION: Diagnostic errors (DEs) harm critically ill children. We determined factors associated with DE in the 1st 7 days after pediatric ICU (PICU) admission. METHODS: We performed a retrospective study of 854 randomly-selected non-elective admissions over 1yr to 4 tertiary-referral PICUs. 4-5 PICU clinicians/site reviewed charts using the Safer Dx instrument to identify potential missed opportunities in diagnosis (MODs) during the 1st 7 days after admission; 35% of charts were reviewed by >2 reviewers. Cases with MODs at all sites were reviewed by 4 site PIs as a group who made final DE determinations. We used the Wilcoxon rank-sum test and Fisher’s exact test to compare characteristics of patients with vs. without DE. RESULTS: 13 of 854 (1.5%) patients had a DE within the 1st 7 days after admission. Reviews for DE were 98.6% concordant among multi-reviewer charts, however Κ=0.28 (95%CI: 0.02, 0.84) likely due to low DE prevalence. Most common missed diagnoses were respiratory (31%) and infectious (31%) conditions. Most DEs were discovered during the PICU stay but >24 hrs after admission (46%). One DE caused harm with prolonged hospital stay. Common MODs included failure to consider the diagnosis despite a suggestive history (46%) and failure to broaden diagnostic testing given clinical information (46%). Demographics, presence of complex chronic conditions, illness severity, and admission source were not associated with DE. Patients with DE had more: 1) atypical presentations (23%vs.4%, p=0.012), 2) neurologic chief complaints (46%vs.19%, p=0.025), 3) admitting intensivists >45 yrs old (92%vs.65%, p=0.041), 4) admitting intensivists with more service wks/yr (median 12.8 vs. 10.3 wks, p=0.023), 5) diagnostic uncertainty on admission (77%vs.25%, p < 0.001), and 6) lab tests performed on 1st day (median 20 vs. 8 tests, p=0.013). Patients with DE had more diagnostic discordance between admission and discharge (68%vs.5%, p < 0.001) and had a longer hospital stay (median 14 vs. 4 days, p=0.002). CONCLUSIONS: 1.5% of critically ill children had DEs within the 1st 7 days of PICU admission. DEs were associated with atypical presentations, neurologic complaints, and diagnostic uncertainty, which can help clinicians identify patients on admission who are at high risk for failures in diagnostic reasoning and MODs/DE.
Meta Tag
Content Type Presentation
Knowledge Area Quality and Patient Safety
Knowledge Area Pediatrics
Knowledge Area Worldwide Data
Knowledge Level Advanced
Membership Level Select
Tag Evidence Based Medicine
Tag Epidemiology Outcomes
Tag Pediatrics
Year 2022
diagnostic error
pediatric critical care
factors associated


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