Diagnostic error in children presenting with acute medical illness to a community hospital

Warrick, C. K.; Patel, Poonam; Hyer, Warren; Neale, G.; Sevdalis, Nick; Inwald, David

doi:10.1093/intqhc/mzu066

Cited by 23 publications

(14 citation statements)

References 26 publications

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“…Furthermore, on diagnostic error analysis almost 90% of errors were of the cognitive type, as in adult cases of misdiagnosis . Most of the misdiagnoses, however, were multifactorial, in line with the previous studies, and the accretion of minor errors in health care may add up to adverse events.…”

Section: Discussionsupporting

confidence: 81%

“…Misdiagnosis occurred in 38% of cases and involved multiple types of error. This incidence was higher than a rate of 5.0% in hospitalized children with an acute medical illness at a community hospital in the UK, which may be due to the difficulty of diagnosing bacterial osteomyelitis. There are several reasons for this difficulty: first, infants and small children tend to present with non‐specific symptoms.…”

Section: Discussionmentioning

confidence: 67%

“…Precedent antibiotic use was more highly associated with a misdiagnosis than statistically non‐significant symptoms such as fever and point tenderness. Once oral antibiotic treatment is begun following the initial diagnosis at the clinic or hospital, the symptoms appear to improve temporarily, possibly leading the physician to “premature closure”, often observed in adult osteomyelitis cases, in which the physician stops short of considering the full spectrum of differential diagnoses or performing tests to confirm the initial diagnosis …”

Section: Discussionmentioning

confidence: 99%

“…The patients were categorized into the misdiagnosis and non‐misdiagnosis groups. Misdiagnosis was defined as a difference between the initial and discharge diagnoses . Two pediatricians also evaluated the incidence of errors in the initial diagnosis using “no fault error”, “system‐related error” and “cognitive error” taxonomy (Table ) …”

Section: Methodsmentioning

confidence: 99%

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Diagnostic errors in pediatric bacterial osteomyelitis

Otani

Aizawa

Hataya

et al. 2019

Pediatrics International

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Background: Clinical evidence for improving diagnostic accuracy in pediatric medicine is still scarce. Septic osteomyelitis is sometimes challenging for physicians to diagnose. The aim of this study was to improve patient care through identifying the incidence and reasons for errors in the diagnosis of bacterial osteomyelitis in pediatric patients. Methods: We retrospectively identified patients younger than 16 years with acute or chronic osteomyelitis at Tokyo Metropolitan Children's Medical Center between April 2010 and September 2017. We extracted data on patient demographics, clinical course, symptoms, locus of the lesions, and diagnosis at presentation and discharge. The patients were categorized into the misdiagnosis and non-misdiagnosis groups following a review by two pediatricians. Misdiagnosis was defined as a difference between the initial and discharge diagnosis. The factors in the two groups were compared, and the types of error in the misdiagnosis group were examined. Results: In total 71 patients were enrolled. The median age and proportion of boys was 7.6 years (IQR, 1.4-11.2 years) and 66%, respectively. Misdiagnosis occurred in 27 patients (38.0%). Precedent antibiotic use was independently associated with misdiagnosis (P = 0.044). A cognitive error was observed in 88.3% of the misdiagnosis group. The median number of types of error per case was 2.0 (IQR, 2.0-3.0). Conclusions: The misdiagnosis of septic osteomyelitis in pediatric patients was common and chiefly caused by cognitive errors. Eliminating cognitive errors in diagnosis is highly likely to improve the care of patients with osteomyelitis.

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Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 67%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Diagnostic errors in pediatric bacterial osteomyelitis

Otani

Aizawa

Hataya

et al. 2019

Pediatrics International

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“…We previously conducted a study at a district general emergency department (ED) where a 5% DE incidence amongst acute paediatric medical admissions was noted. 3 The study site then introduced a CDC model. This study aimed to determine the impact of CDC on DE incidence.…”

mentioning

confidence: 99%

G330(P) Introduction of consultant delivered care is associated with a reduced incidence of diagnostic errors in acute medical admissins in a district general hospital

et al. 2016

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AimDiagnostic errors (DEs) are common yet under-recognised factors in malpractice claims and often associated with cognitive error.1,2 Consultant delivered care (CDC) is being implemented UK wide to improve patient safety yet its impact on DEs is unstudied. We previously conducted a study at a district general emergency department (ED) where a 5% DE incidence amongst acute paediatric medical admissions was noted.3 The study site then introduced a CDC model. This study aimed to determine the impact of CDC on DE incidence.MethodologyAn observational before and after study utilising our previous data3 as a retrospective control. The methodology of our previous study was repeated for intervention CDC hours (10:00–22:00 Weekdays and 14:00–22:00 weekends) and non-CDC hours (parallel control). Paediatric medical admissions were screened for DEs by identifying changes in diagnosis from admission to discharge and confirmed through case-notes review. DEs were further studied by two reviewers to categorise causative factors using a standardised taxonomy.4 Structured interviews of clinicians were performed and analysed using a thematic framework.5 ResultsDE incidence fell from 5% pre-CDC to 2.0% overall afterwards (RR 2.57 95 CI 1.28–5.15). The DE incidence in the CDC cohort was 2.3% (RR 2.17 95 CI 1–4.75 compared to the retrospective control). DEs were fewer in non-CDC hours compared to the CDC hours at 1.5% but this was not statistically significant. DE cases during CDC hours compared to those in the Warrick cohort were associated with less cognitive errors (RR 0.79, 95 CI 0.65–0.96) but more system errors (RR 1.9 95 CI 1.1–3.3).ConclusionA reduction in DEs was noted following implementation of CDC. There are a number of possible explanations. This could be due to direct consultant involvement, improved trainee supervision or awareness of cognitive bias. The latter could potentially have an impact, through trainees, during non-CDC hours. The significantly lower ED attendances post CDC may mean less system related pressures in which DEs are less likely. Similarly increased paediatric nursing may have improved efficiency and enhanced support for trainee doctors. This study is unable to clarify the impact of these factors and further work into the impact of CDC on DEs is needed.ReferencesSevdalis N, Jacklin R, Arora S, Vincent CA. Thomson RG. Diagnostic Error in a National Incident Reporting System in the UK. Journal of Evaluation in Clinical Practice 2010; 16(6):1276–1281Graber ML. The incidence of diagnostic error in medicine. BMJ Quality & safety 2013; 22(Suppl 2):ii21–ii27Warrick C, Patel P, Hyer W, Neale G, Sevdalis N, Inwald D. Diagnostic error in children presenting with acute medical illness to a community hospital. International journal for quality in health care. Journal of the International Society for Quality in Health Care/ISQua 2014; 26(5):538–546Pope C, van Royen P, Baker R. Qualitative methods in research on healthcare quality. Quality & safety in health care 2002; 11(2):148–152Graber ML, Franklin N, Gordon R. ...

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A national physician survey of diagnostic error in paediatrics

et al. 2016

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• Diagnostic errors are an important source of preventable patient harm and have an estimated incidence of 10-15 %. • They are multifactorial in origin and include cognitive, system-related and situational factors. What is New: • We identified a low rate of self-perceived diagnostic error in contrast to the existing literature. • Incomplete history and examination, inadequate staffing levels and excessive workload are cited as the principal contributing factors to diagnostic error in this study.

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Diagnostic error in children presenting with acute medical illness to a community hospital

Cited by 23 publications

References 26 publications

Diagnostic errors in pediatric bacterial osteomyelitis

Diagnostic errors in pediatric bacterial osteomyelitis

G330(P) Introduction of consultant delivered care is associated with a reduced incidence of diagnostic errors in acute medical admissins in a district general hospital

A national physician survey of diagnostic error in paediatrics

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