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BackgroundDiagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs.MethodsWe developed a web-based survey in which physicians participating in the international Paediatric Emergency Research Network representing five out of six WHO regions, described examples of MOIDs involving their own or a colleague's patients. Respondents provided case summaries and answered questions regarding harm and factors contributing to the event.ResultsOf 1594 physicians surveyed, 412 (25.8%) responded (mean age=43 years (SD=9.2), 42.0% female, mean years in practice=12 (SD=9.0)). Patient presentations involving MOIDs had common undifferentiated symptoms at initial presentation, including abdominal pain (21.1%), fever (17.2%) and vomiting (16.5%). Patients were discharged from the ED with commonly reported diagnoses, including acute gastroenteritis (16.7%), viral syndrome (10.2%) and constipation (7.0%). Most reported MOIDs (65%) were detected on ED return visits (46% within 24 hours and 76% within 72 hours). The most common reported MOID was appendicitis (11.4%), followed by brain tumour (4.4%), meningitis (4.4%) and non-accidental trauma (4.1%). More than half (59.1%) of the reported MOIDs involved the patient/parent-provider encounter (eg, misinterpreted/ignored history or an incomplete/inadequate physical examination). Types of MOIDs and contributing factors did not differ significantly between countries. More than half of patients had either moderate (48.7%) or major (10%) harm due to the MOID.ConclusionsAn international cohort of paediatric ED physicians reported several MOIDs, often in children who presented to the ED with common undifferentiated symptoms. Many of these were related to patient/parent-provider interaction factors such as suboptimal history and physical examination. Physicians' personal experiences offer an underexplored source for investigating and mitigating diagnostic errors in the paediatric ED.

Introduction: We sought to validate a handheld, near-infrared spectroscopy (NIRS) device for detecting intracranial hematomas in children with head injury.Methods: Eligible patients were those 3.5 milliliters in volume and 0.2 on three successive scans. We calculated diagnostic performance measures with corresponding exact two-sided 95% Clopper-Pearson confidence intervals (CI). Hypothesis test evaluated whether predictive performance exceeded chance agreement (predictive Youden’s index > 0).Results: A total of 464 patients were enrolled and 344 met inclusion for primary data analysis: 10.5% (36/344) had evidence of a hematoma on HCT, and 4.7% (16/344) had qualifying hematomas. The handheld brain scanner demonstrated a sensitivity of 58.3% (21/36) and specificity of 67.9% (209/308) for hematomas of any size. For qualifying hematomas the scanner was designed to detect, sensitivity was 81% (13/16) and specificity was 67.4% (221/328). Predictive performance exceeded chance agreement with a predictive Youden’s index of 0.11 (95% CI, 0.10 – 0.15; P < 0.001) for all hematomas, and 0.09 (95% CI, 0.08 – 0.12; P < 0.001) for qualifying hematomas.Conclusion: The handheld brain scanner can non-invasively detect a subset of intracranial hematomas in children and may serve an adjunctive role to head-injury neuroimaging decision rules that predict the risk of clinically significant intracranial pathology after head trauma.

To investigate the relationship between language and diagnostic errors (DxE) in the pediatric emergency department (ED). Electronic trigger identified ED encounters resulting in unplanned hospital admission that occurred within 10 days of an index visit from January 2018 through February 2022. Manual screening of each triggered encounter identified cases where the index visit diagnosis and hospitalization discharge diagnosis differed, and these were screened in for review using the Revised Safer Dx instrument to determine if a diagnostic error (DxE) occurred. Non-English primary language (NEPL) and English-proficient (EP) groups were established based on caregiver language. The primary outcome was the proportion of DxE each group. Data were analyzed using univariate analysis and multivariable logistic regression to identify independent predictors of DxE. Electronic trigger identified 3,551 patients, of which 806 (22.7 %) screened in for Safer Dx review. 172 (21.3 %) experienced DxE. The proportion of DxE was similar between EP and NEPL groups (21.5 vs. 21.7 %; p=0.97). Age≥12 years and fewer prior admissions in the preceding 6 months predicted higher odds of DxE. NEPL did not predict higher odds of DxE. NEPL was not associated with increased odds DxE resulting in unplanned admission. [ABSTRACT FROM AUTHOR]

To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis. Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined. Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2–89.9) and specificity of 61.3 % (95 % confidence interval 56.0–65.4). Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review. [ABSTRACT FROM AUTHOR]

Keywords: decision-making; emergency medicine; feedback; quality improvement EN decision-making emergency medicine feedback quality improvement 216 224 9 05/12/22 20220501 NES 220501 Introduction Clinicians are the agents of diagnosis and serve a critical role in reducing diagnostic errors [[1]], [[2]], [[3]]. Numerous feedback modalities exist in emergency departments (EDs), including case-based feedback, morbidity and mortality case conferences, automatic discharge summary routing to clinicians, patient return notifications, performance metric reports, and patient satisfaction surveys [[5], [12]]. Additionally, our survey results demonstrated that feedback delivery from clinicians with similar or more training and experience, transparency about case review, and consistent feedback including examples of optimal care and evidence-based recommendations, were the most important aspects for structuring case-based feedback. [Extracted from the article]

Objectives: Few studies describe the impact of antimicrobial stewardship programs (ASPs) on recognizing and preventing diagnostic errors. Handshake stewardship (HS-ASP) is a novel ASP model that prospectively reviews hospital-wide antimicrobial usage with recommendations made in person to treatment teams. The purpose of this study was to determine if HS-ASP could identify and intervene on potential diagnostic errors for children hospitalized at a quaternary care children’s hospital. Methods: Previously self-identified “Great Catch” (GC) interventions by the Children’s Hospital Colorado HS-ASP team from 10/2014 through 5/2018 were retrospectively reviewed. Each GC was categorized based on the types of recommendations from HS-ASP, including if any diagnostic recommendations were made to the treatment team. Each GC was independently scored using the “Safer Dx Instrument” to determine presence of diagnostic error based on a previously determined cut-off score of ≤1.50. Interrater reliability for the instrument was measured using a randomized subset of one third of GCs. Results: During the study period, there were 162 GC interventions. Of these, 65 (40%) included diagnostic recommendations by HS-ASP and 19 (12%) had a Safer Dx Score of ≤1.50, (Κ=0.44; moderate agreement). Of those GCs associated with diagnostic errors, the HS-ASP team made a diagnostic recommendation to the primary treatment team 95% of the time. Conclusions: Handshake stewardship has the potential to identify and intervene on diagnostic errors for hospitalized children. [ABSTRACT FROM AUTHOR]

We conducted a prospective study of children and adolescents (n = 176; mean age = 13.0 ±2.7 years; 38% female) assessed acutely post-concussion and again 30 days later. We investigated the association between symptom burden and quality of life (QOL) outcomes, as well as the effect of age on QOL. We assessed QOL using patient-reported Pediatric Quality of Life Inventory 4.0, and symptoms using the Health and Behavior Inventory (HBI). Acute (<2 days post-injury) HBI ratings demonstrated a low correlation (R2 = 0.08) with physical health QOL and a moderate correlation with psychosocial health QOL (R2 = 0.21) 30 days post-concussion. HBI ratings 30 days post-concussion demonstrated a moderately high correlation with physical health QOL (R2 = 0.35) and psychosocial health QOL (R2 = 0.57). Age was not significantly associated with physical or psychosocial QOL ratings. Impairments in QOL following concussion may identify children and adolescents who need additional referral to address persistent symptoms at this time. [ABSTRACT FROM AUTHOR]

This study investigates the relationship between the general question, “Is your child/are you back to normal?” and a validated postconcussive symptom scale when assessing symptom resolution following concussion. Children with acute concussion were enrolled during an emergency department visit. Sensitivity and specificity analyses compared the true/false question, “My child is/I am back to normal” at 3 days postinjury with the Concussion Symptom Inventory (CSI; gold standard). A total of 201 participants were enrolled in the study with complete data. The true/false questions of “My child is/I am back to normal” had sensitivities of 78.4% and 59.3% and specificities of 75.0% and 86.4% for caregiver and child responses, respectively, when compared with their corresponding CSI. This study demonstrates that asking a parent or child if the child is back to normal has poor sensitivity and modest specificity in determining if a child’s symptoms have resolved within 3 days of sustaining a concussion relative to a standardized symptom scale. [ABSTRACT FROM AUTHOR]