TY - JOUR
T1 - Diagnostic Errors in a PICU
T2 - Insights from the Morbidity and Mortality Conference
AU - Cifra, Christina L.
AU - Jones, Kareen L.
AU - Ascenzi, Judith A.
AU - Bhalala, Utpal S.
AU - Bembea, Melania M.
AU - Newman-Toker, David E.
AU - Fackler, James C.
AU - Miller, Marlene R.
PY - 2015/6/21
Y1 - 2015/6/21
N2 - Objectives: To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process. Design: Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports. Setting: Single tertiary referral PICU in Baltimore, MD. Patients: Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012. Interventions: None. Measurements and Main Results: Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events. Conclusions: Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive-and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.
AB - Objectives: To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process. Design: Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports. Setting: Single tertiary referral PICU in Baltimore, MD. Patients: Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012. Interventions: None. Measurements and Main Results: Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events. Conclusions: Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive-and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.
KW - diagnostic errors
KW - patient safety
KW - pediatric intensive care unit
KW - quality improvement
UR - http://www.scopus.com/inward/record.url?scp=84937545741&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84937545741&partnerID=8YFLogxK
U2 - 10.1097/PCC.0000000000000398
DO - 10.1097/PCC.0000000000000398
M3 - Article
C2 - 25838150
AN - SCOPUS:84937545741
SN - 1529-7535
VL - 16
SP - 468
EP - 476
JO - Pediatric Critical Care Medicine
JF - Pediatric Critical Care Medicine
IS - 5
ER -