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. 2021 Aug 1;22(8):701-712.
doi: 10.1097/PCC.0000000000002735.

Diagnostic Errors in Pediatric Critical Care: A Systematic Review

Christina L Cifra  1 , Jason W Custer  2 , Hardeep Singh  3 , James C Fackler  4
Affiliations

Diagnostic Errors in Pediatric Critical Care: A Systematic Review

Christina L Cifra et al. Pediatr Crit Care Med. .

Abstract

Objectives: To summarize the literature on prevalence, impact, and contributing factors related to diagnostic error in the PICU.

Data sources: Search of PubMed, EMBASE, and the Cochrane Library up to December 2019.

Study selection: Studies on diagnostic error and the diagnostic process in pediatric critical care were included. Non-English studies with no translation, case reports/series, studies providing no information on diagnostic error, studies focused on non-PICU populations, and studies focused on a single condition/disease or a single diagnostic test/tool were excluded.

Data extraction: Data on research design, objectives, study sample, and results pertaining to the prevalence, impact, and factors associated with diagnostic error were abstracted from each study.

Data synthesis: Using independent tiered review, 396 abstracts were screened, and 17 studies (14 full-text, 3 abstracts) were ultimately included. Fifteen of 17 studies (88%) had an observational research design. Autopsy studies (autopsy rates were 20-47%) showed a 10-23% rate of missed major diagnoses; 5-16% of autopsy-discovered diagnostic errors had a potential adverse impact on survival and would have changed management. Retrospective record reviews reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions and 21-25% of patients discussed at PICU morbidity and mortality conferences. Cardiovascular, infectious, congenital, and neurologic conditions were most commonly misdiagnosed. Systems factors (40-67%), cognitive factors (20-3%), and both systems and cognitive factors (40%) were associated with diagnostic error. Limited information was available on the impact of misdiagnosis.

Conclusions: Knowledge of diagnostic errors in the PICU is limited. Future work to understand diagnostic errors should involve a balanced focus between studying the diagnosis of individual diseases and uncovering common system- and process-related determinants of diagnostic error.

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Conflict of interest statement

Dr. Cifra’s institution received funding from the National Institutes of Health and the National Institute for Child Health and Human Development. She receives funding from the Agency for Healthcare Research and Quality (AHRQ) through a K08 grant (HS026965), a subcontract via MedStar Health Research Institute (AHRQ), and an internal start-up grant from the University of Iowa Carver College of Medicine Department of Pediatrics. Dr. Singh is supported by the Veterans Affairs (VA) Health Services Research and Development Service (Presidential Early Career Award for Scientists and Engineers USA 14-274), the VA National Center for Patient Safety, the AHRQ (R01HS27363), the Gordon and Betty Moore Foundation, and the Houston Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413). The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure.
Figure.. Flow diagram of study identification, screening, and inclusion.
PICU – pediatric intensive care unit aStudies excluded that were not focused on diagnostic error included education-related studies, outcomes studies, and work on other types of error. bThree studies included in the final cohort had only abstracts available.
See this image and copyright information in PMC

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