Objective To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors.Study design A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors.Results From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification.Conclusions A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors.

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BackgroundPediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months.MethodsWe reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July–December 2017; 101 charts were reviewed post-intervention, January–June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a ‘complete’ DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric.ResultsAt baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a ‘complete’ DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41–2.47, p = 0.73), but attending-documented DDx did not improve (2.85–2.82, p = 0.88).ConclusionsWe demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.

: Background Despite recognition by both the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Paediatrics (ABP) of the importance of bioethics education, curricular crowding, lack of perceived significance, and insufficient administrative support remain significant barriers to trainees gaining competency in bioethics. Few bioethics curricula at the graduate medical education level are evidence-based or comprehensive. We sought to develop and assess the effectiveness of a Team Based Learning (TBL) curriculum in improving residents’ bioethics knowledge and their ability to evaluate ethical dilemmas. Methods We integrated L. Dee Fink’s curricular design principles of “Significant Learning,” Jonsen et. al ’s “Four-Box Method” of ethical analysis, and ABP bioethics content specifications to create 10 TBL bioethics sessions. Paediatric residents at a major academic centre then completed a 3-year longitudinal, integrated TBL-based bioethics curriculum. Primary outcomes included individual and group readiness assessment tests (iRAT/gRAT), pre-work completion, and satisfaction with sessions. Results The TBL-based bioethics curriculum contains 10 adaptable modules. Paediatric residents ( n = 348 total resident encounters) were highly engaged and satisfied with the curriculum. gRAT scores (mean 89%) demonstrated significant improvement compared to iRAT scores (72%) across all TBLs and all post-graduate years ( p < .001). Higher gRAT scores correlated with higher level of training. Although pre-work completion was low (28%), satisfaction was high (4.42/5 on Likert scale). Conclusions Our TBL-based bioethics curriculum was effective in improving knowledge, practical and flexible in its implementation, and well-received. We attribute its success to its grounding in ethical theory, relevance to ABP specifications, and a multi-modal, engaging format. This curriculum is easily modified to different specialties, virtual formats, or other specific institutional needs. Key messages Despite formidable challenges to teaching bioethics in residency education, evidence-based methods such as Team-Based Learning (TBL) can be employed to increase knowledge and satisfaction. This study reports the first successful TBL bioethics curriculum, planned and executed longitudinally over 3 years, with paediatric residents at a large academic children’s hospital in the US. TBL can be utilised to teach bioethics at the graduate medical education level and is adaptable to different situational factors, disciplines, and levels of clinical experience.