title: Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making.
abstract: BACKGROUND
  Diagnostic error is a significant problem in specialities characterised by diagnostic uncertainty such as primary care, emergency medicine and paediatrics. Despite wide-spread availability, computerised aids have not been shown to significantly improve diagnostic decision-making in a real world environment, mainly due to the need for prolonged system consultation. In this study performed in the clinical environment, we used a Web-based diagnostic reminder system that provided rapid advice with free text data entry to examine its impact on clinicians' decisions in an acute paediatric setting during assessments characterised by diagnostic uncertainty.
  
  
  METHODS
  Junior doctors working over a 5-month period at four paediatric ambulatory units consulted the Web-based diagnostic aid when they felt the need for diagnostic assistance. Subjects recorded their clinical decisions for patients (differential diagnosis, test-ordering and treatment) before and after system consultation. An expert panel of four paediatric consultants independently suggested clinically significant decisions indicating an appropriate and 'safe' assessment. The primary outcome measure was change in the proportion of 'unsafe' workups by subjects during patient assessment. A more sensitive evaluation of impact was performed using specific validated quality scores. Adverse effects of consultation on decision-making, as well as the additional time spent on system use were examined.
  
  
  RESULTS
  Subjects attempted to access the diagnostic aid on 595 occasions during the study period (8.6% of all medical assessments); subjects examined diagnostic advice only in 177 episodes (30%). Senior House Officers at hospitals with greater number of available computer workstations in the clinical area were most likely to consult the system, especially out of working hours. Diagnostic workups construed as 'unsafe' occurred in 47/104 cases (45.2%); this reduced to 32.7% following system consultation (McNemar test, p < 0.001). Subjects' mean 'unsafe' workups per case decreased from 0.49 to 0.32 (p < 0.001). System advice prompted the clinician to consider the 'correct' diagnosis (established at discharge) during initial assessment in 3/104 patients. Median usage time was 1 min 38 sec (IQR 50 sec-3 min 21 sec). Despite a modest increase in the number of diagnostic possibilities entertained by the clinician, no adverse effects were demonstrable on patient management following system use. Numerous technical barriers prevented subjects from accessing the diagnostic aid in the majority of eligible patients in whom they sought diagnostic assistance.
  
  
  CONCLUSIONS
  We have shown that junior doctors used a Web-based diagnostic reminder system during acute paediatric assessments to significantly improve the quality of their diagnostic workup and reduce diagnostic omission errors. These benefits were achieved without any adverse effects on patient management following a quick consultation.
authors.affiliation: Children's Acute Transport Service (CATS), 44B Bedford Row, London, WC1H 4LL, UK. ramnarayan@msn.com
authors.forename: Padmanabhan
authors.initials: P
authors.lastname: Ramnarayan
authors.forename: Andrew
authors.initials: A
authors.lastname: Winrow
authors.forename: Michael
authors.initials: M
authors.lastname: Coren
authors.forename: Vasanta
authors.initials: V
authors.lastname: Nanduri
authors.forename: Roger
authors.initials: R
authors.lastname: Buchdahl
authors.forename: Benjamin
authors.initials: B
authors.lastname: Jacobs
authors.forename: Helen
authors.initials: H
authors.lastname: Fisher
authors.forename: Paul M
authors.initials: PM
authors.lastname: Taylor
authors.forename: Jeremy C
authors.initials: JC
authors.lastname: Wyatt
authors.forename: Joseph
authors.initials: J
authors.lastname: Britto
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data*; D003936:Diagnosis, Computer-Assisted / Q000706:statistics & numerical data*; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D006779:Hospitals, Public; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010043:Outcome and Process Assessment, Health Care; D010044:Outpatient Clinics, Hospital / Q000592:standards; D010372:Pediatrics / Q000379:methods*; D017010:Reminder Systems; D018570:Risk Assessment; D017751:Safety Management / Q000379:methods*; D011795:Surveys and Questionnaires; D035501:Uncertainty; D006113:United Kingdom