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

Abstract

Objective: To determine incidence and aetiology of diagnostic errors in children presenting with acute medical illness to a community hospital.

Design: A three-stage study was conducted. Stage 1: retrospective case note review, comparing admission to discharge diagnoses of children admitted to hospital, to determine incidence of diagnostic error. Stage 2: cases of suspected misdiagnosis were examined in detail by two reviewers. Stage 3: structured interviews were conducted with clinicians involved in these cases to identify contributory factors.

Setting: UK community (District General) hospital.

Participants: All medical patients admitted to the paediatric ward and patients transferred from the Emergency Department to a different facility over a 90-day period were included.

Main outcome measures: Incidence of diagnostic error, type of diagnostic error and content analysis of the structured interviews to determine frequency of emerging themes.

Results: Incidence of misdiagnosis in children presenting with acute illness was 5.0% (19/378, 95% confidence interval (CI) 2.8-7.2%). Diagnostic errors were multi-factorial in origin, commonly involving cognitive factors. Reviewers 1 and 2 identified a median of three and four errors per case, respectively. In 14 cases, structured interviews were possible; clinicians believed system-related errors (organizational flaws, e.g. inadequate policies, staffing or equipment) contributed more commonly to misdiagnoses, whereas reviewers found cognitive factors contributed more commonly to diagnostic error.

Conclusions: Misdiagnoses occurred in 5% of children presenting with acute illness and were multi-factorial in aetiology. Multi-site longitudinal studies further exploring aetiology of errors and effect of educational interventions are required to generalize these findings and determine strategies for mitigation.

Keywords: cognitive bias; diagnostic error; paediatrics.