Abstract
Background: Diagnostic errors are a global health priority and a common cause of preventable harm. There is limited data available for the prevalence of misdiagnosis in pediatric acute-care settings. Respiratory illnesses, which are particularly challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments.Objective: To evaluate the diagnostic accuracy of emergency department clinicians in diagnosing acute childhood respiratory diseases, as compared with expert panel consensus (reference standard).Methods: Prospective, multicenter, single-blinded, diagnostic accuracy study in two well-resourced pediatric emergency departments in a large Australian city. Between September 2016 and August 2018, a convenience sample of children aged 29 days to 12 years who presented with respiratory symptoms was enrolled. The emergency department discharge diagnoses were reported by clinicians based upon standard clinical diagnostic definitions. These diagnoses were compared against consensus diagnoses given by an expert panel of pediatric specialists using standardized disease definitions after they reviewed all medical records.Results: For 620 participants, the sensitivity and specificity (%, [95% CI]) of the emergency department compared with the expert panel diagnoses were generally poor: isolated upper respiratory tract disease (64.9 [54.6, 74.4], 91.0 [88.2, 93.3]), croup (76.8 [66.2, 85.4], 97.9 [96.2, 98.9]), lower respiratory tract disease (86.6 [83.1, 89.6], 92.9 [87.6, 96.4]), bronchiolitis (66.9 [58.6, 74.5], 94.3 [80.8, 99.3]), asthma/reactive airway disease (91.0 [85.8, 94.8], 93.0 [90.1, 95.3]), clinical pneumonia (63·9 [50.6, 75·8], 95·0 [92·8, 96·7]), focal (consolidative) pneumonia (54·8 [38·7, 70·2], 86.2 [79.3, 91.5]). Only 59% of chest x-rays with consolidation were correctly identified. Between 6.9 and 14.5% of children were inappropriately prescribed based on their eventual diagnosis.Conclusion: In well-resourced emergency departments, we have identified a previously unrecognized high diagnostic error rate for acute childhood respiratory disorders, particularly in pneumonia and bronchiolitis. These errors lead to the potential of avoidable harm and the administration of inappropriate treatment.
Highlights
Diagnostic errors are the most common form of medical error and are defined as “the failure to make an accurate and timely explanation of the patient’s health problem or to communicate that explanation to the patient” [1]
Diagnostic errors are classified by the World Health Organization (WHO) as a global health priority and are regarded as a “moral, professional and public health imperative” by the U.S National Academy of Medicine [1], there are a lack of published data and reliable measures in this area, in child health
The proportion of participants positive for each study diagnosis were similar at both sites, except for bronchiolitis, where more participants were recruited at the tertiary site (120/145 vs. 25/35, p = 0.016, subjects
Summary
Diagnostic errors are the most common form of medical error and are defined as “the failure to make an accurate and timely explanation of the patient’s health problem or to communicate that explanation to the patient” [1]. Diagnostic error research has been hindered, in part, because clinicians are generally poor at recognizing their own mistakes, if they have not been formally trained to identify errors [2,3,4]. With these findings in mind, reported error rates are likely to be underestimates. Diagnostic errors are a global health priority and a common cause of preventable harm. Respiratory illnesses, which are challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments
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