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 Measure(s). 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 systemrelated 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. Multisite longitudinal studies further exploring aetiology of errors and effect of educational interventions are required to generalize these findings and determine strategies for mitigation.