Preferred language and diagnostic errors in the pediatric emergency department.

OBJECTIVES: To investigate the relationship between language and diagnostic errors (DxE) in the pediatric emergency department (ED). METHODS: Electronic trigger identified ED encounters resulting in unplanned hospital admission that occurred within 10 days of an index visit from January 2018 through February 2022. Manual screening of each triggered encounter identified cases where the index visit diagnosis and hospitalization discharge diagnosis differed, and these were screened in for review using the Revised Safer Dx instrument to determine if a diagnostic error (DxE) occurred. Non-English primary language (NEPL) and English-proficient (EP) groups were established based on caregiver language. The primary outcome was the proportion of DxE each group. Data were analyzed using univariate analysis and multivariable logistic regression to identify independent predictors of DxE. RESULTS: Electronic trigger identified 3,551 patients, of which 806 (22.7 %) screened in for Safer Dx review. 172 (21.3 %) experienced DxE. The proportion of DxE was similar between EP and NEPL groups (21.5 vs. 21.7 %; p=0.97). Age≥12 years and fewer prior admissions in the preceding 6 months predicted higher odds of DxE. NEPL did not predict higher odds of DxE. CONCLUSIONS: NEPL was not associated with increased odds DxE resulting in unplanned admission.

Comparative Perspectives on Diagnostic Error Discussions Between Inpatient and Outpatient Pediatric Providers.

Diagnostic error remains understudied and underaddressed despite causing significant morbidity and mortality. One barrier to addressing this issue remains provider discomfort. Survey studies have shown significantly more discomfort among providers in discussing diagnostic error compared with other forms of error. Whether the comfort in discussing diagnostic error differs depending on practice setting has not been previously studied. The objective of this study was to assess differences in provider willingness to discuss diagnostic error in the inpatient versus outpatient setting. A multicenter survey was sent out to 3881 providers between May and June 2018. This survey was designed to assess comfort level of discussing diagnostic error and looking at barriers to discussing diagnostic error. Forty-three percent versus 22% of inpatient versus outpatient providers (P = 0.004) were comfortable discussing short-term diagnostic error publicly. Similarly, 76% versus 60% of inpatient versus outpatient providers (P = 0.010) were comfortable discussing short-term diagnostic error privately. A higher percentage of inpatient (64%) compared with outpatient providers (46%) (P = 0.043) were comfortable discussing long-term diagnostic error privately. Forty percent versus 24% of inpatient versus outpatient providers (P = 0.018) were comfortable discussing long-term error publicly. No difference in barriers cited depending on practice setting. Inpatient providers are more comfortable discussing diagnostic error than their outpatient counterparts. More study is needed to determine the etiology of this discrepancy and to develop strategies to increase outpatient provider comfort.

Clinical Pathway Adherence and Missed Diagnostic Opportunities Among Children with Musculoskeletal Infections.

INTRODUCTION: Clinical care pathways (CPs) integrate best evidence into the local care delivery context to promote efficiency and patient safety. However, the impact of CPs on diagnostic performance remains poorly understood. The objectives of this study were to evaluate adherence to a musculoskeletal infection (MSKI) diagnostic CP and identify recurrent failure points leading to missed diagnostic opportunities (MDOs). METHODS: Retrospective chart review was performed from January 2018 to February 2022 for children 6 months to 18 years of age who had an unplanned admission for MSKI after being evaluated and discharged from the pediatric emergency department (PED) for related complaints within the previous 10 days. MDOs were identified using the Revised Safer Dx. Demographic and clinical characteristics of children with and without MDOs were compared using bivariate descriptive statistics. An improvement team reviewed the diagnostic trajectories of MDOs for deviations from the MSKI CP and developed a fishbone diagram to describe contributing factors to CP deviations. RESULTS: The study identified 21 children with and 13 children without MSKI-associated MDOs. Children with MDOs were more likely to have an initial C-reactive protein value > 2 mg/dL (90.0% vs. 0%, p = 0.01) and returned to care earlier than children without MDOs (median 2.8 days vs. 6.7 days, p = 0.004). Factors contributing to MDOs included failure to obtain screening laboratory tests, misinterpretation of laboratory values, failure to obtain orthopedic consultation, and failure to obtain definitive imaging. CONCLUSION: Several recurrent deviations from an MSKI diagnostic CP were found to be associated with MDOs. Future quality improvement efforts to improve adherence to this MSKI CP may prevent MDOs.

Multicenter evaluation of a method to identify delayed diagnosis of diabetic ketoacidosis and sepsis in administrative data.

OBJECTIVES: To derive a method of automated identification of delayed diagnosis of two serious pediatric conditions seen in the emergency department (ED): new-onset diabetic ketoacidosis (DKA) and sepsis. METHODS: Patients under 21 years old from five pediatric EDs were included if they had two encounters within 7 days, the second resulting in a diagnosis of DKA or sepsis. The main outcome was delayed diagnosis based on detailed health record review using a validated rubric. Using logistic regression, we derived a decision rule evaluating the likelihood of delayed diagnosis using only characteristics available in administrative data. Test characteristics at a maximal accuracy threshold were determined. RESULTS: Delayed diagnosis was present in 41/46 (89 %) of DKA patients seen twice within 7 days. Because of the high rate of delayed diagnosis, no characteristic we tested added predictive power beyond the presence of a revisit. For sepsis, 109/646 (17 %) of patients were deemed to have a delay in diagnosis. Fewer days between ED encounters was the most important characteristic associated with delayed diagnosis. In sepsis, our final model had a sensitivity for delayed diagnosis of 83.5 % (95 % confidence interval 75.2-89.9) and specificity of 61.3 % (95 % confidence interval 56.0-65.4). CONCLUSIONS: Children with delayed diagnosis of DKA can be identified by having a revisit within 7 days. Many children with delayed diagnosis of sepsis may be identified using this approach with low specificity, indicating the need for manual case review.

OUTCOMES OF MISSED DIAGNOSIS OF PEDIATRIC APPENDICITIS, NEW-ONSET DIABETIC KETOACIDOSIS, AND SEPSIS IN FIVE PEDIATRIC HOSPITALS.

BACKGROUND: Missed diagnosis can predispose to worse condition-specific outcomes. OBJECTIVE: To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis. METHODS: We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance. RESULTS: We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis. CONCLUSIONS: Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network.

BACKGROUND: Diagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs. METHODS: We developed a web-based survey in which physicians participating in the international Paediatric Emergency Research Network representing five out of six WHO regions, described examples of MOIDs involving their own or a colleague's patients. Respondents provided case summaries and answered questions regarding harm and factors contributing to the event. RESULTS: Of 1594 physicians surveyed, 412 (25.8%) responded (mean age=43 years (SD=9.2), 42.0% female, mean years in practice=12 (SD=9.0)). Patient presentations involving MOIDs had common undifferentiated symptoms at initial presentation, including abdominal pain (21.1%), fever (17.2%) and vomiting (16.5%). Patients were discharged from the ED with commonly reported diagnoses, including acute gastroenteritis (16.7%), viral syndrome (10.2%) and constipation (7.0%). Most reported MOIDs (65%) were detected on ED return visits (46% within 24 hours and 76% within 72 hours). The most common reported MOID was appendicitis (11.4%), followed by brain tumour (4.4%), meningitis (4.4%) and non-accidental trauma (4.1%). More than half (59.1%) of the reported MOIDs involved the patient/parent-provider encounter (eg, misinterpreted/ignored history or an incomplete/inadequate physical examination). Types of MOIDs and contributing factors did not differ significantly between countries. More than half of patients had either moderate (48.7%) or major (10%) harm due to the MOID. CONCLUSIONS: An international cohort of paediatric ED physicians reported several MOIDs, often in children who presented to the ED with common undifferentiated symptoms. Many of these were related to patient/parent-provider interaction factors such as suboptimal history and physical examination. Physicians' personal experiences offer an underexplored source for investigating and mitigating diagnostic errors in the paediatric ED.

Identification of delayed diagnosis of paediatric appendicitis in administrative data: a multicentre retrospective validation study.

OBJECTIVE: To derive and validate a tool that retrospectively identifies delayed diagnosis of appendicitis in administrative data with high accuracy. DESIGN: Cross-sectional study. SETTING: Five paediatric emergency departments (EDs). PARTICIPANTS: 669 patients under 21 years old with possible delayed diagnosis of appendicitis, defined as two ED encounters within 7 days, the second with appendicitis. OUTCOME: Delayed diagnosis was defined as appendicitis being present but not diagnosed at the first ED encounter based on standardised record review. The cohort was split into derivation (2/3) and validation (1/3) groups. We derived a prediction rule using logistic regression, with covariates including variables obtainable only from administrative data. The resulting trigger tool was applied to the validation group to determine area under the curve (AUC). Test characteristics were determined at two predicted probability thresholds. RESULTS: Delayed diagnosis occurred in 471 (70.4%) patients. The tool had an AUC of 0.892 (95% CI 0.858 to 0.925) in the derivation group and 0.859 (95% CI 0.806 to 0.912) in the validation group. The positive predictive value (PPV) for delay at a maximal accuracy threshold was 84.7% (95% CI 78.2% to 89.8%) and identified 87.3% of delayed cases. The PPV at a stricter threshold was 94.9% (95% CI 87.4% to 98.6%) and identified 46.8% of delayed cases. CONCLUSIONS: This tool accurately identified delayed diagnosis of appendicitis. It may be used to screen for potential missed diagnoses or to specifically identify a cohort of children with delayed diagnosis.

Early aerobic exercise among adolescents at moderate/high risk for persistent post-concussion symptoms: A pilot randomized clinical trial.

PURPOSE: To determine the proportion of adolescents at moderate/high risk for Persistent Postconcussion Symptoms (PPCS) who develop PPCS when randomized to early aerobic exercise or standard-of-care and examine exercise volume/intensity between groups. METHODS: Using a randomized clinical trial design, we enrolled patients 10-18 years of age who obtained a "Predicting/Preventing Postconcussive Problems in Pediatrics" (5P) risk score ≥6 and enrolled/tested ≤ one-week post-concussion (mean = 5.5 ± 1.5 days post-concussion). Participants were randomized to "Exercise" (5 days/week, 20 min/day aerobic exercise at individualized intensity [80% HR at exercise test cessation]) or "Standard-of-Care" (no exercise recommendations). They returned for re-testing one-month post-concussion, and we remotely monitored exercise between assessments. RESULTS: Sixteen participants enrolled (intervention: n = 9, 56% female, 14.2 ± 2.1 years; standard-of-care: n = 7, 57% female, 13.6 ± 1.7 years). A smaller proportion of the early aerobic exercise group developed PPCS when compared to the standard-of-care group (44% vs. 86%; relative risk = 0.52; 95% confidence interval = 0.34-1.36; number-needed-to-treat = 2.4). CONCLUSION: We observed that participants randomized to early aerobic exercise had a lower risk of PPCS compared to standard-of-care. Although not statistically significant, these results suggest early/individualized aerobic exercise among those at moderate/high PPCS risk may be effective at reducing that risk, and early aerobic exercise is not detrimental to recovery outcomes.

Use of e-triggers to identify diagnostic errors in the paediatric ED.

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.

Diagnostic Accuracy of Suspected Appendicitis: A Comparative Analysis of Misdiagnosed Appendicitis in Children.

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.

Evaluation of feedback modalities and preferences regarding feedback on decision-making in a pediatric emergency department.

OBJECTIVES: To compare pediatric emergency clinicians' attitudes toward three feedback modalities and assess clinicians' case-based feedback preferences. METHODS: Electronic survey sent to pediatric emergency medicine (PEM) physicians and fellows; general pediatricians; and advanced practice providers (APPs) with nine questions exploring effectiveness and emotional impact of three feedback modalities: case-based feedback, bounce-back notifications, and biannual performance reports. Additional questions used a four-point ordinal agreement response scale and assessed clinicians' attitudes toward case review notification, case-based feedback preferences, and emotional support. Survey responses were compared by feedback modality using Pearson's chi-squared. RESULTS: Of 165 eligible providers, 93 (56%) responded. Respondents agreed that case-based feedback was timely (81%), actionable (75%), prompted reflection on decision-making (92%), prompted research on current clinical practice (53%), and encouraged practice change (58%). Pediatric Emergency Care Applied Research Network (PECARN) performance reports scored the lowest on all metrics except positive feedback. No more than 40% of providers indicated that any feedback modality provided emotional support. Regarding case-based feedback, 88% of respondents desired email notification before case review and 88% desired feedback after case review. Clinicians prefer receiving feedback from someone with similar or more experience/training. Clinicians receiving feedback desire succinctness, supporting evidence, consistency, and sensitive delivery. CONCLUSIONS: Case-based feedback scored highest of the three modalities and is perceived to be the most likely to improve decision-making and promote practice change. Most providers did not perceive emotional support from any feedback modality. Emotional safety warrants purposeful attention in feedback delivery. Critical components of case-based feedback include succinctness, supporting evidence, consistency, and sensitive delivery.

Clinical Features and Preventability of Delayed Diagnosis of Pediatric Appendicitis.

Importance: Delayed diagnosis of appendicitis is associated with worse outcomes than timely diagnosis, but clinical features associated with diagnostic delay are uncertain, and the extent to which delays are preventable is unclear. Objective: To determine clinical features associated with delayed diagnosis of pediatric appendicitis, assess the frequency of preventable delay, and compare delay outcomes. Design, Setting, and Participants: This case-control study included 748 children treated at 5 pediatric emergency departments in the US between January 1, 2010, and December 31, 2019. Participants were younger than 21 years and had a diagnosis of appendicitis. Exposures: Individual features of appendicitis and pretest likelihood of appendicitis were measured by the Pediatric Appendicitis Risk Calculator (pARC). Main Outcomes and Measures: Case patients had a delayed diagnosis of appendicitis, defined as 2 emergency department visits leading to diagnosis and a case review showing the patient likely had appendicitis at the first visit. Control patients had a single emergency department visit yielding a diagnosis. Clinical features and pARC scores were compared by case-control status. Preventability of delay was assessed as unlikely, possible, or likely. The proportion of children with indicated imaging based on an evidence-based cost-effectiveness threshold was determined. Outcomes of delayed diagnosis were compared by case-control status, including hospital length of stay, perforation, and multiple surgical procedures. Results: A total of 748 children (mean [SD] age, 10.2 [4.3] years; 392 boys [52.4%]; 427 White children [57.1%]) were included in the study; 471 (63.0%) had a delayed diagnosis of appendicitis, and 277 (37.0%) had no delay in diagnosis. Children with a delayed diagnosis were less likely to have pain with walking (adjusted odds ratio [aOR], 0.16; 95% CI, 0.10-0.25), maximal pain in the right lower quadrant (aOR, 0.12; 95% CI, 0.07-0.19), and abdominal guarding (aOR, 0.33; 95% CI, 0.21-0.51), and were more likely to have a complex chronic condition (aOR, 2.34; 95% CI, 1.05-5.23). The pretest likelihood of appendicitis was 39% to 52% lower in children with a delayed vs timely diagnosis. Among children with a delayed diagnosis, 109 cases (23.1%) were likely to be preventable, and 247 (52.4%) were possibly preventable. Indicated imaging was performed in 104 (22.0%) to 289 (61.3%) children with delayed diagnosis, depending on the imputation method for missing data on white blood cell count. Patients with delayed diagnosis had longer hospital length of stay (mean difference between the groups, 2.8 days; 95% CI, 2.3-3.4 days) and higher perforation rates (OR, 7.8; 95% CI, 5.5-11.3) and were more likely to undergo 2 or more surgical procedures (OR, 8.0; 95% CI, 2.0-70.4). Conclusions and Relevance: In this case-control study, delayed appendicitis was associated with initially milder symptoms but worse outcomes. These findings suggest that a majority of delayed diagnoses were at least possibly preventable and that many of these patients did not undergo indicated imaging, suggesting an opportunity to prevent delayed diagnosis of appendicitis in some children.

Intracranial Traumatic Hematoma Detection in Children Using a Portable Near-infrared Spectroscopy Device.

INTRODUCTION: We sought to validate a handheld, near-infrared spectroscopy (NIRS) device for detecting intracranial hematomas in children with head injury. METHODS: Eligible patients were those <18 years old who were admitted to the emergency department at three academic children's hospitals with head trauma and who received a clinically indicated head computed tomography (HCT). Measurements were obtained by a blinded operator in bilateral frontal, temporal, parietal, and occipital regions. Qualifying hematomas were a priori determined to be within the brain scanner's detection limits of >3.5 milliliters in volume and <2.5 centimeters from the surface of the brain. The device's measurements were positive if the difference in optical density between hemispheres was >0.2 on three successive scans. We calculated diagnostic performance measures with corresponding exact two-sided 95% Clopper-Pearson confidence intervals (CI). Hypothesis test evaluated whether predictive performance exceeded chance agreement (predictive Youden's index > 0). RESULTS: A total of 464 patients were enrolled and 344 met inclusion for primary data analysis: 10.5% (36/344) had evidence of a hematoma on HCT, and 4.7% (16/344) had qualifying hematomas. The handheld brain scanner demonstrated a sensitivity of 58.3% (21/36) and specificity of 67.9% (209/308) for hematomas of any size. For qualifying hematomas the scanner was designed to detect, sensitivity was 81% (13/16) and specificity was 67.4% (221/328). Predictive performance exceeded chance agreement with a predictive Youden's index of 0.11 (95% CI, 0.10 - 0.15; P < 0.001) for all hematomas, and 0.09 (95% CI, 0.08 - 0.12; P < 0.001) for qualifying hematomas. CONCLUSION: The handheld brain scanner can non-invasively detect a subset of intracranial hematomas in children and may serve an adjunctive role to head-injury neuroimaging decision rules that predict the risk of clinically significant intracranial pathology after head trauma.

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors.

OBJECTIVES: Few studies describe the impact of antimicrobial stewardship programs (ASPs) on recognizing and preventing diagnostic errors. Handshake stewardship (HS-ASP) is a novel ASP model that prospectively reviews hospital-wide antimicrobial usage with recommendations made in person to treatment teams. The purpose of this study was to determine if HS-ASP could identify and intervene on potential diagnostic errors for children hospitalized at a quaternary care children's hospital. METHODS: Previously self-identified "Great Catch" (GC) interventions by the Children's Hospital Colorado HS-ASP team from 10/2014 through 5/2018 were retrospectively reviewed. Each GC was categorized based on the types of recommendations from HS-ASP, including if any diagnostic recommendations were made to the treatment team. Each GC was independently scored using the "Safer Dx Instrument" to determine presence of diagnostic error based on a previously determined cut-off score of ≤1.50. Interrater reliability for the instrument was measured using a randomized subset of one third of GCs. RESULTS: During the study period, there were 162 GC interventions. Of these, 65 (40%) included diagnostic recommendations by HS-ASP and 19 (12%) had a Safer Dx Score of ≤1.50, (Κ=0.44; moderate agreement). Of those GCs associated with diagnostic errors, the HS-ASP team made a diagnostic recommendation to the primary treatment team 95% of the time. CONCLUSIONS: Handshake stewardship has the potential to identify and intervene on diagnostic errors for hospitalized children.

Severe SARS-CoV-2 Infection in a Pediatric Patient Requiring Extracorporeal Membrane Oxygenation.

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.

Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey.

INTRODUCTION: Meaningful conversations about diagnostic errors require safety cultures where clinicians are comfortable discussing errors openly. However, clinician comfort discussing diagnostic errors publicly and barriers to these discussions remain unexplored. We compared clinicians' comfort discussing diagnostic errors to other medical errors and identified barriers to open discussion. METHODS: Pediatric clinicians at 4 hospitals were surveyed between May and June 2018. The survey assessed respondents' comfort discussing medical errors (with varying degrees of system versus individual clinician responsibility) during morbidity and mortality conferences and privately with peers. Respondents reported the most significant barriers to discussing diagnostic errors publicly. Poststratification weighting accounted for nonresponse bias; the Benjamini-Hochberg adjustment was applied to control for false discovery (significance set at P < 0.018). RESULTS: Clinicians (n = 838; response rate 22.6%) were significantly less comfortable discussing all error types during morbidity and mortality conferences than privately (P < 0.004) and significantly less comfortable discussing diagnostic errors compared with other medical errors (P < 0.018). Comfort did not differ by clinician type or years in practice; clinicians at one institution were significantly less comfortable discussing diagnostic errors compared with peers at other institutions. The most frequently cited barriers to discussing diagnostic errors publicly included feeling like a bad clinician, loss of reputation, and peer judgment of knowledge base and decision-making. CONCLUSIONS: Clinicians are more uncomfortable discussing diagnostic errors than other types of medical errors. The most frequent barriers involve the public perception of clinical performance. Addressing this aspect of safety culture may improve clinician participation in efforts to reduce harm from diagnostic errors.