title: Finding Diagnostic Errors in Children Admitted to the PICU.
abstract: OBJECTIVE
  To determine whether the Safer Dx Instrument, a structured tool for finding diagnostic errors in primary care, can be used to reliably detect diagnostic errors in patients admitted to a PICU.
  
  
  METHODS
  The Safer Dx Instrument consists of 11 questions to evaluate the diagnostic process and a final question to determine if diagnostic error occurred. We used the instrument to analyze four "high-risk" patient cohorts admitted to the PICU between June 2013 and December 2013.
  
  
  METHODS
  High-risk cohorts were defined as cohort 1: patients who were autopsied; cohort 2: patients seen as outpatients within 2 weeks prior to PICU admission; cohort 3: patients transferred to PICU unexpectedly from an acute care floor after a rapid response and requiring vasoactive medications and/or endotracheal intubation due to decompensation within 24 hours; and cohort 4: patients transferred to PICU unexpectedly from an acute care floor after a rapid response without subsequent decompensation in 24 hours.
  
  
  METHODS
  Two clinicians used the instrument to independently review records in each cohort for diagnostic errors, defined as missed opportunities to make a correct or timely diagnosis. Errors were confirmed by senior expert clinicians.
  
  
  RESULTS
  Diagnostic errors were present in 26 of 214 high-risk patient records (12.1%; 95% CI, 8.2-17.5%) with the following frequency distribution: cohort 1: two of 16 (12.5%); cohort 2: one of 41 (2.4%); cohort 3: 13 of 44 (29.5%); and cohort 4: 10 of 113 (8.8%). Overall initial reviewer agreement was 93.6% (κ, 0.72). Infections and neurologic conditions were the most commonly missed diagnoses across all high-risk cohorts (16/26).
  
  
  CONCLUSIONS
  The Safer Dx Instrument has high reliability and validity for diagnostic error detection when used in high-risk pediatric care settings. With further validation in additional clinical settings, it could be useful to enhance learning and feedback about diagnostic safety in children.
authors.affiliation: 1Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX. 2Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX. 3Department of Family & Community Medicine, Baylor College of Medicine, Houston, TX.
authors.forename: Maria Caridad
authors.initials: MC
authors.lastname: Davalos
authors.forename: Kenya
authors.initials: K
authors.lastname: Samuels
authors.forename: Ashley N D
authors.initials: AN
authors.lastname: Meyer
authors.forename: Satid
authors.initials: S
authors.lastname: Thammasitboon
authors.forename: Moushumi
authors.initials: M
authors.lastname: Sur
authors.forename: Kevin
authors.initials: K
authors.lastname: Roy
authors.forename: Aymer
authors.initials: A
authors.lastname: Al-Mutairi
authors.forename: Hardeep
authors.initials: H
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003422:Critical Care / Q000592:standards* / Q000706:statistics & numerical data; D003951:Diagnostic Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric / Q000592:standards* / Q000706:statistics & numerical data; D008297:Male; D010043:Outcome and Process Assessment, Health Care / Q000379:methods; D011785:Quality Assurance, Health Care / Q000379:methods*; D058996:Quality Improvement; D015203:Reproducibility of Results; D018570:Risk Assessment; D012680:Sensitivity and Specificity