Table 1.
Prevalence of Diagnostic Error in the Pediatric Intensive Care Unit
| Authors | Year | Research Design | Relevant Sample | Prevalence of Diagnostic Error | Types of Most Commonly Misdiagnosed Conditions |
|---|---|---|---|---|---|
| Autopsy Studies | |||||
| Custer JW, et al. (8) | 2015 | Systematic review of 7 PICU autopsy studies | 498 PICU patients with autopsies included in 7 studies (47% autopsy rate) | 20% major diagnostic error rate (6% Class I, 14% Class II)a | 45% infection, 29% vascular events, 10% congenital malformations (among Class I and II errors*) |
| Widmann R, et al. (9) | 2017 | Retrospective cohort | 39 patients with autopsies admitted to a single PICU (20% autopsy rate) | 6% major diagnostic error rate (2% Class I, 4% Class II)a | 38% congenital malformations, 25% vascular, 25% infection (among Class I and II errors*) |
| Carlotti AP, et al. (10) | 2016 | Retrospective cohort | 123 patients with autopsies admitted to a single PICU | 23% major diagnostic error rate (16% Class I, 7% Class II)a | 71% cardiovascular, 14% infection, 7% cancer (among Class I and II errorsa); 14% of major diagnostic errors were undiagnosed complications of care/surgery |
| Blanco C, et al. (11) | 2014 | Retrospective cohort | 54 patients admitted to a single PICU who required ECMO | 54% major diagnostic error rate (74% Class I, 28% Class II)a | 65% cardiovascular, 10% infection, 4% neurologic (among Class I and II errors*) |
| Retrospective Cohort Studies | |||||
| Cifra CL, et al. (12) | 2018 | Retrospective cohort - chart review using the Safer Dx Instrument | 50 patients non-electively admitted to a single PICU (consecutive admissions) | 8% diagnostic error rate in the first 12 hours of PICU admission | 50% neurologic, 50% infection |
| Davalos MC, et al. (13) | 2017 | Retrospective cohort - chart review using the Safer Dx Instrument | 214 patients admitted to a single PICU (selected from cohorts hypothesized to be at high risk for diagnostic error) | 12% overall diagnostic error rate; 30% of diagnostic errors were among patients transferred from an acute care floor and required hemodynamic and invasive respiratory support within the first 24 hours of PICU admission | 31% neurologic, 31% infection, 19% gastrointestinal |
| Cifra CL, et al. (14) | 2014 | Retrospective cohort - review of conference minutes, chart review, review of incident reports | 96 patients discussed at a single PICU’s morbidity and mortality conference | 21% diagnostic error rate; diagnostic error comprised 7% of all adverse events | Not specified |
| Cifra CL, et al. (15) | 2015 | Retrospective cohort - review of conference minutes, chart review | 96 patients discussed at a single PICU’s morbidity and mortality conference | 21% diagnostic error rate | 35% vascular, 30% neurologic, 20% infection, 20% cardiac |
| Frey B, et al. (16) | 2018 | Retrospective cohort - review of conference minutes | 48 patients discussed at a single PICU’s morbidity and mortality conference | 25% overall diagnostic error rate; 66% of autopsied patients had a discrepancy between clinical diagnosis and autopsy findings | Not specified overall Among autopsied patients: 38% vascular, 33% genetic/metabolic, 29% infection |
| Fink AZ, et al. (17) | 2018 | Retrospective cohort | 575 radiographs of patients admitted to a single PICU | 46% discrepancy rate in interpretation of radiographs between PICU clinicians and radiologists; 13% were actionable discrepancies | Most common actionable discrepancies: 35% line/tube placement, 18% lung findings, 15% air leak |
| Nesterova GV, et al. (18) | 2010 | Retrospective cohort | 460 radiographs of patients admitted to a single PICU | 7% discrepancy rate in interpretation of radiographs between PICU clinicians and radiologists; 9% were actionable discrepancies | Overall most common discrepancies: 30% air space disease, 27% atelectasis, 24% effusion |
| Other Studies | |||||
| Labib JR, et al. (19) | 2019 | Quasi-experimental pre-test/post-test design | 215 incident reports submitted regarding the care of 918 patients admitted to 4 PICUs | 5% diagnostic errors detailed in incident reports | Infection (not quantified) |
| Bhat PN, et al. (20) | 2018 | Cross-sectional survey | 200 pediatric cardiac ICU clinicians | 79% of respondents reported encountering ≥ 5 diagnostic errors yearly; 65% of respondents reported encountering ≥ 5 harmful diagnostic errors yearly | 37% medication side effects, 21% psychiatric conditions, 17% sepsis |
PICU - pediatric intensive care unit, ECMO - extra-corporeal membrane oxygenation
a
According to the Goldman classification, missed major diagnoses are categorized as Class I and II diagnostic errors. Class I errors had a potential adverse impact on survival and would have changed medical management, while Class II errors had no potential impact on survival and would not have changed therapy (5).