Diagnostic Errors in the Pediatric and Neonatal ICU

Custer, Jason W.; Winters, Bradford D.; Goode, Victoria; Robinson, Karen A.; Yang, Ting; Pronovost, Peter J.; Newman‐Toker, David E.

doi:10.1097/pcc.0000000000000274

Cited by 68 publications

(50 citation statements)

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“…13 Es motivo de preocupación la marcada declinación de su práctica en el mundo y, particularmente, en nuestro país. Publicaciones de la Sociedad Argentina de Pediatría reflejan la magnitud del problema en artículos y editoriales con títulos tales como "Volver a la autopsia o seguir ignorando la verdad".…”

Section: Discussionunclassified

¿Cuál es el valor de la autopsia neonatal? Correlación anatomoclínica en 135 casos

2017

Arch Argent Pediat

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RESUMENIntroducción. La autopsia neonatal es un valioso método diagnóstico y esencial para el asesoramiento familiar sobre futuros embarazos. Población y métodos. Estudio retrospectivo que incluyó todas las autopsias de neonatos fallecidos en la Clínica y Maternidad Suizo Argentina desde enero de 1998 a diciembre de 2006. Se determinó la tasa de autopsias y se compararon los diagnósticos obtenidos de las historias clínicas con los resultados de estas. Resultados. Sobre el total de 227 niños fallecidos,se realizaron 135 autopsias (tasa de 59,5%). En el 25%,la concordancia fue completa. En el 26%, se halló nueva información con significativa implicancia para el asesoramiento genético. Conclusiones. La tasa de autopsias fue del 59,5%. La correlación anatomoclínica y sus insospechados hallazgos con implicancia para el asesoramiento genético muestran la importancia de la práctica sistemática de la autopsia neonatal. INTRODUCCIÓNLa autopsia, utilizada como método de diagnóstico desde el siglo XV, ha tenido un papel fundamental en el progreso del conocimiento médico. En el período neonatal es particularmente valiosa, pues además de brindar información objetiva sobre las causas de la muerte, permite, en muchos casos de hallazgos inesperados, un correcto asesoramiento con directa implicancia para el futuro planeamiento familiar.A pesar de la innegable importancia de la autopsia, su realización comenzó a disminuir considerablemente en el mundo a partir de la década del setenta, 1,2 tanto en neonatos como en niños y adultos. En Argentina, las cifras publicadas sobre autopsias en recién nacidos confirman esta marcada declinación. 3,4 OBJETIVOSDeterminar la prevalencia de autopsias y analizar la correlación entre los diagnósticos clínicos y los hallazgos anatomopatológicos. POBLACIÓN Y MÉTODOSEstudio retrospectivo y observacional que incluyó el total de autopsias de recién nacidos fallecidos en el Servicio de Neonatología de la Clínica y Maternidad Suizo Argentina, durante un período de 9 años (enero de 1998 -diciembre de 2006). El estudio fue realizado con la aprobación del Comité de Ética en Investigación de la Institución.El pedido de la autopsia a los padres fue realizado en todos los casos por médicos de planta, coordinadores o jefes del Servicio de N e o n a t o l o g í a . E n e s e a c t o , s e e x p l i c ó l a importancia del estudio, en qué consistía el procedimiento y el plazo en que sería completado para que pudieran planear la inhumación. Se obtuvo, asimismo, un consentimiento informado firmado por los padres.Todas las autopsias fueron realizadas por la misma patóloga perinatal y su equipo. Se obtuvieron cariotipo, radiografías de cuerpo entero y fotografías externas en todos los casos.E l e x a m e n e x t e r n o , l a a n t r o p o m e t r í a y la evisceración se realizaron dentro de las 48 horas del óbito y se estudiaron macro-y microscópicamente todos los órganos internos. Se realizaron ateneos anatomoclínicos en 101/135 (75%) casos.El resultado de las autopsias fue comunicado en todos los casos a los p...

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Section: Discussionunclassified

¿Cuál es el valor de la autopsia neonatal? Correlación anatomoclínica en 135 casos

2017

Arch Argent Pediat

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“…In a recent systematic review, Custer et al (16) found major diagnostic errors (Goldman classes 1 and 2) in 19.6% of autopsies in the PICU and neonatal ICU setting. Our study identified missed major diagnoses in 21 of 32 autopsies (66%).…”

Section: Discussionmentioning

confidence: 99%

“…Wherever the possibility of error was raised, we analyzed whether it met with participant consensus. Error categories included ventilator, invasive (e.g., vascular) device, medical or surgical procedure, infection, drugs, miscommunication (with patient/parents or between staff), and diagnosis (9,16,17). We then attributed to each error the most appropriate root cause, whether individual or system-based, such as organization, interface issues, milieu, and equipment dysfunction (9).…”

Section: Methodsmentioning

confidence: 99%

“…We analyzed the protocols of all MMCs held since the implementation of the structured approach with respect to the following parameters: morbidity/mortality, moderator profile, participants, patient characteristics (age, sex, term or premature birth, diagnosis, treatment complication as a main reason for admission, surgery, cardiac catheterization, and ECMO), autopsy data as a pointer to relevant new diagnoses classified by Goldman criteria (15,16), and death/morbidity event-MMC interval. Wherever the possibility of error was raised, we analyzed whether it met with participant consensus.…”

Section: Methodsmentioning

confidence: 99%

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The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

Frey

Doell

Klauwer

et al. 2016

Pediatric Critical Care Medicine

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OBJECTIVES: To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety. DESIGN: Retrospective analysis. SETTING: Tertiary interdisciplinary neonatal PICU. PATIENTS: Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors' PICU implemented a morbidity and mortality conference guideline in 2009 using a system-based approach to identify medical errors, their contributing factors, and possible solutions. In the subsequent 5.5 years, there were 44 mortality conferences (of 181 deaths [27%] over the same period) and four morbidity conferences. The median death/morbidity event-morbidity and mortality conference interval was 90 days (range, 7 d to 1.5 yr). The median age of patients was 4 months (range, newborn to 17 years). In six cases, the primary reason for PICU admission was a treatment complication. Unsafe processes/medical errors were identified and discussed in 37 morbidity and mortality conferences (77%). In seven cases, new autopsy findings prompted the discussion of a possible error. The 48 morbidity and mortality conferences identified 50 errors, including 30 in which an interface problem was a contributing factor. Fifty-four improvements were identified in 34 morbidity and mortality conferences. Four morbidity and mortality conferences discussed specific ethical issues. CONCLUSIONS: From our experience, we have found that the interdisciplinary and interprofessional morbidity and mortality conference has the potential to reveal unsafe processes/medical errors, in particular, diagnostic and communication errors and interface problems. When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors. Originally published at: Frey, Bernhard; Doell, Carsten; Klauwer, Dietrich; Cannizzaro, Vincenzo; Bernet, Vera; Maguire, Christine; Brotschi, Barbara (2016). The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety. Pediatric Critical Care Medicine, 17(1):67-72.

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“…13 The marked decline in autopsies worldwide is a cause for concern, especially in Argentina. Publications of the Argentine Society of Pediatrics reflect the size of this problem in an editorial comment titled Going back to autopsy or continuing to ignore the truth.…”

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confidence: 99%

What is the value of neonatal autopsy? Pathological and clinical correlation in 135 cases

Tamanaha¹,

Fuksman²,

Pedraza³

et al. 2017

Arch Argent Pediat

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Introduction.Neonatal autopsy is a valuable, critical diagnostic method to provide genetic counseling for future pregnancies. Population and methods. Retrospective study including all neonatal autopsies performed on deceased neonates at Clínica y Maternidad Suizo Argentina between January 1998 and December 2006. The rate of autopsies was established; the diagnosis indicated in the medical record was compared to autopsy findings. Results. Out of 227 deceased infants, 135 autopsies were performed (rate: 59.5%). Concordance was complete in 25% of autopsies. New information was found in 26%, which had significant implications for genetic counseling. INTRODUCTIONAutopsy has been used as a diagnostic method since the 15 th century and has played a critical role in medical advances. It is particularly valuable in the neonatal period because in addition to providing objective information on the cause of death, it allows -in the face of many unexpected findings-to provide adequate counseling with direct implications for future family planning.In spite of their undeniable relevance, the use of autopsies started to decline considerably worldwide as of the 1970s, 1,2 either on newborn infants, children, or adults. In Argentina, publications on the number of autopsies performed on newborn infants confirm such marked decline. 3,4 OBJECTIVESTo establish the prevalence of autopsies and analyze the correlation between clinical diagnosis and anatomopathological findings. POPULATION AND METHODSThis was a retrospective and observational study including all autopsies performed on deceased newborn infants at the Division of Neonatology of Clínica y Maternidad Suizo Argentina over a 9-year period (January 1998 to December 2006). The study was approved by the hospital's Research Ethics Committee.Parents were asked to authorize the autopsy by staff physicians, coordinators or heads of the Division of Neonatology. They explained the study relevance, what the procedure included, and how long it would take so that parents could make burial arrangements. In addition, parents were asked to sign an informed consent.All autopsies were performed by the same perinatal pathologist and her team. A karyotype test was done, and whole body X-ray images and external photos were taken in all cases.External examination, anthropometric profile, and evisceration were done within 48 hours of death, and macro-and microscopic examinations were done on all organs. Grand rounds were conducted to discuss pathological and clinical findings of 101/135 (75%) cases.Autopsy results were reported to the parents during meetings with the treating neonatologists in the two months following their child's death.The diagnosis obtained from the medical record was compared to that made during the autopsy using Goldman's classification as modified by Kumar 5,6 ( (27 cases). When doubts were raised in relation to the interpretation of anatomopathological reports, these were discussed with the pathologist (RF). The rate of autopsies was estimated based on the total nu...

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Diagnostic Errors in the Pediatric and Neonatal ICU

Abstract: Diagnostic errors in PICU/neonatal ICU populations are most commonly due to infection. Further research is needed to better quantify pediatric intensive care-related misdiagnosis and to define potential strategies to reduce their frequency or mitigate misdiagnosis-related harm.

Cited by 68 publications

References 36 publications

¿Cuál es el valor de la autopsia neonatal? Correlación anatomoclínica en 135 casos

¿Cuál es el valor de la autopsia neonatal? Correlación anatomoclínica en 135 casos

The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

What is the value of neonatal autopsy? Pathological and clinical correlation in 135 cases

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