Joseph A. Grubenhoff

Background Efforts to improve diagnosis should reflect the unique needs of children; however, there is no consensus on paediatric-specific priority areas. Methods An expert panel of 25 United States (US) paediatric diagnostic excellence researchers, patient safety leaders and family partners from 15 institutions participated in a modified Delphi panel. Panellists participated in generating a literature-derived list of topics relevant to improving diagnosis. Panellists then rated agreement on each topic as a research or operational improvement priority. Topics that achieved consensus (≥75% of panellists rating them as high priority) were subsequently rated based on feasibility for implementation at the respondent’s institution. Results Literature review identified 24 topics relevant to paediatric diagnostic safety and quality, which were expanded to 62 topics during the initial panel discussion and grouped into 25 survey topics. Consensus was reached on 6 topics as research priorities and 11 as operational improvement priorities. Of these, three were deemed highly feasible for research and three for operational improvement. Research priorities included: identifying paediatric conditions at high risk for diagnostic error, developing communication methods to enhance the diagnostic process and establishing diagnostic process feedback mechanisms. Operational improvement priorities included: identifying care delivery or health services scenarios at high risk for diagnostic error, establishing interdisciplinary, structured review of cases of diagnostic error and encouraging reporting of missed opportunities for improving diagnostic safety. Conclusion Experts successfully prioritised important and feasible topics in research and practice for improving paediatric diagnosis in US academic medical centres.

Introduction: Well-calibrated diagnostic performance requires feedback on decisions. Emergency department and urgent care (ED/UC) clinicians infrequently receive diagnostic performance feedback. We explored clinician experience with self-directed diagnostic performance review compared with diagnostic safety expert review. Methods: Single-center, cohort study of pediatric ED/UC clinician self-directed case review involving possible diagnostic errors (DxEs). Participants reviewed their care of patients admitted within 10 days of an index ED/UC visit at risk of DxEs. The Revised Safer Dx provided structure for DxE identification and was compared with expert review by two diagnostic safety experts using Cohen kappa. Participants also reported their experience using the Revised Safer Dx. Results: During the 1-year study period, 187 patients at risk of DxEs received index visit care from 260 ED/UC eligible clinicians. Seventy-one clinicians submitted reviews for 97 patient–clinician encounters (37.4% response rate). Agreement on the presence of DxEs ranged from 84.8% to 87.5%; Cohen kappa for expert 1 = 0.51 (95% confidence interval = 0.25–0.76); expert 2 = 0.54 (95% confidence interval = 0.17–0.92) indicating moderate agreement. More than 60% of participants agreed that the Revised Safer Dx provided a useful framework for reviewing diagnostic performance regardless of the presence of a DxE. Participants self-identifying a DxE were significantly more likely to have altered their diagnostic approach than those who did not (75.0% vs 5.7%; P < .001). Discussion: ED/UC clinicians performing self-directed structured review for DxEs demonstrated moderate agreement with diagnostic safety experts indicating this method may aid diagnostic reasoning calibration. Promoting self-directed reviews may improve feedback delivery among ED/UC clinicians.

Saunders et al describe trends in pediatric and nonpediatric emergency department (ED) visits and hospitalizations for acute mental health–related concerns amon

Background Diagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting. Objectives To assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems. Design/methods Retrospective single-centre cohort study of children ages 0–22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems. Results An e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen’s κ=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital’s incident reporting system and five to the ED case review team (one reported to both). Conclusion An e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs.

Objective: When evaluating suspected appendicitis, limited data support quality benchmarks for negative appendectomy (NA); none exist for delayed diagnosis of appendicitis (DDA). The objectives of this study are the following: (1) to provide preliminary evidence supporting a quality benchmark for DDA and 2) to compare presenting features and diagnostic evaluations of children with NA and DDA with those with pathology-confirmed appendicitis (PCA) diagnosed during initial emergency department (ED) encounter. Methods: Secondary analysis of data from a QI project designed to reduce the use computed tomography when evaluating suspected appendicitis using a case-control design. Patients undergoing appendectomy in an academic tertiary care children's hospital system between January 1, 2015, and December 31, 2016 (n = 1,189) were eligible for inclusion in this case-control study. Negative appendectomy was defined as no pathologic change or findings consistent with a different diagnosis. Delayed diagnosis of appendicitis was defined as patients undergoing appendectomy within 7 days of a prior ED visit for a related complaint. Controls of PCA (n = 150) were randomly selected from all cases undergoing appendectomy. Results: There were 42 NA (3.5%) and 31 DDA (2.6%). Cases of PCA and NA exhibited similar histories, examination findings, and underwent comparable diagnostic evaluations. Cases of PCA more frequently demonstrated a white blood cell count greater than 10 × 10³/μL (85% vs 67%; P = 0.01), a left-shift (77% vs 45%; P < 0.001), and an ultrasound interpretation with high probability for appendicitis (73% vs 54%; P = 0.03). Numerous significant differences in history, examination findings, and diagnostic tests performed existed between cases of PCA and DDA. Conclusions: Children with PCA and NA present similarly and undergo comparable evaluations resulting in appendectomy. A 3% to 4% NA rate may be unavoidable given these similarities. Presenting features in DDA significantly differ from those of PCA. An irreducible proportion of appendicitis diagnoses may be delayed.

The overwhelming majority of pediatric cases of SARS-CoV-2 infection are mild or asymptomatic with only a handful of pediatric deaths reported. We present a case of severe COVID-19 infection in a pediatric patient with signs of hyperinflammation and consumptive coagulopathy requiring intubation and extracorporeal membrane oxygenation (ECMO) and eventual death due to ECMO complications.