Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study∗

Christina L. Cifra; Jason W. Custer; Craig M. Smith; Kristen A. Smith; Dayanand N. Bagdure; Jodi Bloxham; Emily Goldhar; Stephen M. Gorga; Elizabeth M. Hoppe; Christina D. Miller; Max Pizzo; Sonali Ramesh; Joseph Riffe; Katharine Robb; Shari L. Simone; Haley D. Stoll; Jamie Ann Tumulty; Stephanie E. Wall; Katie K. Wolfe; Linder Wendt; Patrick Ten Eyck; Christopher P. Landrigan; Jeffrey D. Dawson; Heather Schacht Reisinger; Hardeep Singh; Loreen A. Herwaldt

doi:10.1097/CCM.0000000000005942

Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study∗

Christina L. Cifra^*, Jason W. Custer, Craig M. Smith, Kristen A. Smith, Dayanand N. Bagdure, Jodi Bloxham, Emily Goldhar, Stephen M. Gorga, Elizabeth M. Hoppe, Christina D. Miller, Max Pizzo, Sonali Ramesh, Joseph Riffe, Katharine Robb, Shari L. Simone, Haley D. Stoll, Jamie Ann Tumulty, Stephanie E. Wall, Katie K. Wolfe, Linder WendtPatrick Ten Eyck, Christopher P. Landrigan, Jeffrey D. Dawson, Heather Schacht Reisinger, Hardeep Singh, Loreen A. Herwaldt

^*Corresponding author for this work

Pediatrics

Research output: Contribution to journal › Article › peer-review

4 Scopus citations

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.

Original language	English (US)
Pages (from-to)	1492-1501
Number of pages	10
Journal	Critical care medicine
Volume	51
Issue number	11
DOIs	https://doi.org/10.1097/CCM.0000000000005942
State	Published - Nov 1 2023

Funding

Drs. Cifra, Smith, Riffe, Landrigan, and Dawson’s institutions received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development through a K12 grant to the University of Iowa Stead Family Department of Pediatrics (no. HD027748-28) and the National Center for Advancing Translational Sciences. Drs. Cifra, KA Smith, Riffe, Landrigan, Dawson, and Herwaldt’s institutions received funding from the Agency for Healthcare Research and Quality (AHRQ) through a K08 grant (no. HS026965). This work was further supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (no. UL1TR002537) through the University of Iowa’s Institute for Clinical and Translational Science. Dr. Cifra received funding from the AHRQ, MedStar Research Institute, and De Gruyter. Drs. Cifra, CM Smith, KA Smith, Riffe, Ten Eyck, Landrigan, and Dawson received support for article research from the National Institutes of Health. Drs. Custer and Tumulty’s institution received funding from University of Iowa. Dr. Miller’s institution received funding from the University of Iowa Department of Pediatrics. Dr. Landrigan received funding from I-PASS Institute and Missouri Hospital Association Executive Speakers Bureau. Dr. Singh is funded in part by the Houston Veterans Administration (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness, and Safety (CIN13–413), the VA HSR&D Service (IIR17–127 and the Presidential Early Career Award for Scientists and Engineers USA 14–274), the VA National Center for Patient Safety, the Agency for Healthcare Research and Quality (R01HS27363), and the Gordon and Betty Moore Foundation. He disclosed government work. Dr. Herwaldt’s institution received funding from the Centers for Disease Control and Prevention; she disclosed that Professional Disposables International, Inc. (PDI) is providing a product for a clinical trial. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Keywords

critical care
diagnostic error
patient safety
pediatrics
quality improvement

ASJC Scopus subject areas

Critical Care and Intensive Care Medicine

Access to Document

10.1097/CCM.0000000000005942

Cite this

Cifra, C. L., Custer, J. W., Smith, C. M., Smith, K. A., Bagdure, D. N., Bloxham, J., Goldhar, E., Gorga, S. M., Hoppe, E. M., Miller, C. D., Pizzo, M., Ramesh, S., Riffe, J., Robb, K., Simone, S. L., Stoll, H. D., Tumulty, J. A., Wall, S. E., Wolfe, K. K., ... Herwaldt, L. A. (2023). Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study∗. Critical care medicine, 51(11), 1492-1501. https://doi.org/10.1097/CCM.0000000000005942

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title = "Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study∗",

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.",

keywords = "critical care, diagnostic error, patient safety, pediatrics, quality improvement",

author = "Cifra, {Christina L.} and Custer, {Jason W.} and Smith, {Craig M.} and Smith, {Kristen A.} and Bagdure, {Dayanand N.} and Jodi Bloxham and Emily Goldhar and Gorga, {Stephen M.} and Hoppe, {Elizabeth M.} and Miller, {Christina D.} and Max Pizzo and Sonali Ramesh and Joseph Riffe and Katharine Robb and Simone, {Shari L.} and Stoll, {Haley D.} and Tumulty, {Jamie Ann} and Wall, {Stephanie E.} and Wolfe, {Katie K.} and Linder Wendt and {Ten Eyck}, Patrick and Landrigan, {Christopher P.} and Dawson, {Jeffrey D.} and Reisinger, {Heather Schacht} and Hardeep Singh and Herwaldt, {Loreen A.}",

year = "2023",

month = nov,

day = "1",

doi = "10.1097/CCM.0000000000005942",

language = "English (US)",

volume = "51",

pages = "1492--1501",

journal = "Critical care medicine",

issn = "0090-3493",

publisher = "Lippincott Williams and Wilkins",

number = "11",

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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, Ten Eyck, P, Landrigan, CP, Dawson, JD, Reisinger, HS, Singh, H & Herwaldt, LA 2023, 'Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study∗', Critical care medicine, vol. 51, no. 11, pp. 1492-1501. https://doi.org/10.1097/CCM.0000000000005942

TY - JOUR

T1 - Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care

T2 - A Multicenter Study∗

AU - Cifra, Christina L.

AU - Custer, Jason W.

AU - Smith, Craig M.

AU - Smith, Kristen A.

AU - Bagdure, Dayanand N.

AU - Bloxham, Jodi

AU - Goldhar, Emily

AU - Gorga, Stephen M.

AU - Hoppe, Elizabeth M.

AU - Miller, Christina D.

AU - Pizzo, Max

AU - Ramesh, Sonali

AU - Riffe, Joseph

AU - Robb, Katharine

AU - Simone, Shari L.

AU - Stoll, Haley D.

AU - Tumulty, Jamie Ann

AU - Wall, Stephanie E.

AU - Wolfe, Katie K.

AU - Wendt, Linder

AU - Ten Eyck, Patrick

AU - Landrigan, Christopher P.

AU - Dawson, Jeffrey D.

AU - Reisinger, Heather Schacht

AU - Singh, Hardeep

AU - Herwaldt, Loreen A.

PY - 2023/11/1

Y1 - 2023/11/1

N2 - 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.

AB - 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.

KW - critical care

KW - diagnostic error

KW - patient safety

KW - pediatrics

KW - quality improvement

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Prevalence and Characteristics of Diagnostic Error in Pediatric Critical Care: A Multicenter Study∗

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