Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study

J Perinatol. 2022 Oct;42(10):1312-1318. doi: 10.1038/s41372-022-01359-9. Epub 2022 Mar 4.


Objective: To determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients.

Study design: We conducted a retrospective cohort study of 600 consecutive inborn admissions. A physician used the "Safer Dx NICU Instrument" to review the electronic health record for the first 7 days of admission, and categorized cases as "yes," "unclear," or "no" for diagnostic error. A secondary reviewer evaluated all "yes" charts plus a random sample of charts in the other categories. Subsequently, all secondary reviewers reviewed records with discordance between primary and secondary review to arrive at consensus.

Results: We identified 37 diagnostic errors (6.2% of study patients) with "substantial agreement" between reviewers (κ = 0.66). The most common diagnostic process breakdown was missed maternal history (51%).

Conclusion: The frequency of diagnostic error in inborn NICU patients during the first 7 days of admission is 6.2%.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Diagnostic Errors
  • Electronic Health Records*
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal*
  • Retrospective Studies