Diagnostic Errors: Impact of an Educational Intervention on Pediatric Primary Care

Julianne Nemes Walsh, DNP, PNP-BC; Margaret Knight, PhD; A. James Lee, PhD


J Pediatr Health Care. 2018;32(1):53-62. 

In This Article

Abstract and Introduction


Introduction The purpose of our study was to determine the impact of an educational program on a provider's knowledge related to diagnostic errors and diagnostic reasoning strategies.

Methods A quasi-experimental interventional study with a multimedia approach, case study discussion, and trigger-generated medical record review at two time points was conducted. Measurement tools included a test developed by the National Patient Safety Foundation, Reducing Diagnostic Errors: Strategies for Solutions Quiz, additional diagnostic reasoning questions, and a trigger-generated process to analyze medical records.

Results Knowledge related to diagnostic errors statistically improved from the pretest to posttest scores with sustained 60-day differences (p < .025). Although there was a decline in the proportion of patients returning with the same chief complaint within 14 days, this was not statistically significant (p < .15). When providers were confronted with an unrecognizable clinical presentation, they reported an increased use of a "diagnostic timeout" (p < .038).

Discussion Providers developed an increased awareness of the presence of diagnostic errors in the primary care setting, the contributing risk factors for a diagnostic error, and possible strategies to reduce diagnostic errors. These factors had an unexpected impact on changing the primary care practice model to enhance the continuity of patient care.


Diagnostic errors are the sixth leading cause of death in the United States, are ranked as the leading cause of paid malpractice claims in primary care, and are twice as likely to cause a patient death compared with any other type of error (Carroll and Buddenbaum, 2007, CRICO Foundation, 2014, Graber, 2013, Institute of Medicine, 2015, Singh et al., 2014). A recent report published by the IOM (2015), Improving Diagnosis in Health Care, highlighted the multifactorial causes of diagnostic errors and recognized that diagnosis is a collaborative effort between health care professionals, patients, and families. In the report, the IOM defines a diagnostic error as a failure to establish an accurate and timely explanation of the patient's health problem or communicate the explanation to the patient.

In 2014, CRICO Foundation released The Annual Benchmarking Report: Malpractice Risk in the Diagnostic Process. This report was generated to determine when and where diagnosis-related errors occur and discusses necessary changes to prevent diagnostic errors. In the report, 23,527 malpractice cases were reviewed, and it was found that the most expensive judgment errors were related to a failure in the diagnostic process. Leading judgment factors included failure or delay in ordering a diagnostic test, misinterpretation of a diagnostic test, failure to establish a differential diagnosis, failure or delay in ordering a consultation, and failure to rule out an abnormal finding. Diagnostic errors in the ambulatory setting are more often due to lapses in clinical judgment (Carroll & Buddenbaum, 2007; CRICO Foundation, 2014, Giardina et al., 2013, Kain and Caldwell-Andrews, 2006).