More Than Half of Pediatricians Report Making Frequent Diagnostic Errors

Pauline Anderson

June 23, 2010

June 23, 2010 — More than half of pediatricians make diagnostic errors at least once a month, and almost half make diagnostic errors that cause harm to patients at least once a year, according to the results of a new survey.

The survey also showed that misdiagnosis of viral illnesses as bacterial illnesses is the most common diagnostic error, followed by misdiagnosis of medication adverse effects and psychiatric diseases.

"Our study provides new data about types of diagnostic errors among children and their cause and lays the groundwork for a multifaceted approach to reduce such errors," wrote the authors, led by Hardeep Singh, MD, from the Houston Veterans Affairs Health Services Research and Development Center of Excellence, Baylor College of Medicine, Texas.

The survey results, collected anonymously, were published online June 21 in Pediatrics.

Development of the survey was a long process that involved a literature review, input from specialists and focus groups, and pilot testing. The 25-item survey, which takes 15 to 20 minutes to complete using the Internet, includes questions that focus on frequency and potential harm for errors related to medications, surgery, and other clinical activities and that assess perceptions of contributing factors and potential solutions.

Researchers sent surveys to 1362 academic pediatricians, trainees, and community-based pediatricians at 3 sites — 2 tertiary-care institutions in Houston and 1 tertiary-care institution in Cincinnati, Ohio — and 109 affiliated clinics. The overall response rate was 53% (n = 726). About a quarter of the respondents (27%) had been in practice for more than 10 years, and two thirds (67%) performed mostly clinical duties.

Many of the survey items ask respondents to rank their first, second, and third choices. The researchers developed an average ranking system, which explains why ranking and percentages may differ.

Of the 6 types of medical errors, respondents ranked errors in diagnosis fourth in frequency and third in potential for harm. More than half (54%) reported that they made a diagnostic error at least once or twice a month. About 45% of respondents reported that errors that harmed patients occurred at least once or twice a year, but only 4% reported that such errors occurred at least once or twice a month.

Diagnosing viral illnesses as bacterial illnesses was the most frequent diagnostic error (52% of total sample), followed by misdiagnosis of medication adverse effects (53%) and psychiatric disorders (32%). "None of these overlap with the top diagnostic errors found in claims files," said the authors. They pointed out that pediatricians consider circumstances surrounding diagnostic errors to be different from those mentioned in pediatric malpractice literature.

"Our study builds on the knowledge available from malpractice literature to enhance our understanding of diagnostic errors that affect children, serving as a guide to the development of strategies to prevent these errors," wrote the authors.

Failure to gather available medical information, for example, history and chart review (48%), was ranked highest among process breakdowns associated with diagnostic error. This was followed by care not being sought in a timely manner by patients or caregivers (42%). "Strategies to empower caregivers and patients should be studied and implemented in the context of patients safety research," said the authors.

System-related errors, organizational issues, or communication problems (79%) were deemed the most common contributing factors for diagnostic error. Inadequate care coordination, teamwork, and/or communication across clinical sites and providers (82%) was rated the most important system-related factor.

Close follow-up of patients (73%) was ranked as the provider-based solution most likely to be effective. As for system-based solutions, access to electronic medical records was ranked highest (74%). "Despite ongoing debate about the benefits of electronic health records, all groups of pediatricians ranked electronic records as the best system-based solution," noted the authors.

About half (48%) of the respondents received training about diagnostic errors in medical school, and 59% in residency. "The lack of emphasis on formal training regarding diagnostic errors provides opportunities to redesign curricula for both future pediatricians and practicing physicians," said the authors.

Among the limitations of the study was that it relied entirely on self-reported error data rather than on actual errors and that its content and design were based largely on adult literature. In addition, as pediatricians may not know when they missed a diagnosis, errors may be underreported.

The study was supported by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 21, 2010.

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