Diagnostic error in children presenting with acute medical illness to a community hospital.

OBJECTIVE: To determine incidence and aetiology of diagnostic errors in children presenting with acute medical illness to a community hospital. DESIGN: A three-stage study was conducted. Stage 1: retrospective case note review, comparing admission to discharge diagnoses of children admitted to hospital, to determine incidence of diagnostic error. Stage 2: cases of suspected misdiagnosis were examined in detail by two reviewers. Stage 3: structured interviews were conducted with clinicians involved in these cases to identify contributory factors. SETTING: UK community (District General) hospital. PARTICIPANTS: All medical patients admitted to the paediatric ward and patients transferred from the Emergency Department to a different facility over a 90-day period were included. MAIN OUTCOME MEASURES: Incidence of diagnostic error, type of diagnostic error and content analysis of the structured interviews to determine frequency of emerging themes. RESULTS: Incidence of misdiagnosis in children presenting with acute illness was 5.0% (19/378, 95% confidence interval (CI) 2.8-7.2%). Diagnostic errors were multi-factorial in origin, commonly involving cognitive factors. Reviewers 1 and 2 identified a median of three and four errors per case, respectively. In 14 cases, structured interviews were possible; clinicians believed system-related errors (organizational flaws, e.g. inadequate policies, staffing or equipment) contributed more commonly to misdiagnoses, whereas reviewers found cognitive factors contributed more commonly to diagnostic error. CONCLUSIONS: Misdiagnoses occurred in 5% of children presenting with acute illness and were multi-factorial in aetiology. Multi-site longitudinal studies further exploring aetiology of errors and effect of educational interventions are required to generalize these findings and determine strategies for mitigation.

Guidance for withdrawal and withholding of intensive care as part of neonatal end-of-life care.

INTRODUCTION: Advances in foetal medicine and neonatology have enabled increased antenatal diagnosis of life-limiting conditions and improved preterm survival, escalating the debate surrounding the ethics of neonatal end-of-life care and withholding or withdrawing intensive care. SOURCES OF DATA: Literature search of MEDLINE and the Cochrane library databases using the search terms [neonatal palliative care] AND [neonatal AND withdrawal of intensive care and treatment]. Review of consensus statements and guidelines. AREAS OF AGREEMENT: UK practice is aided by Grade 3-4 evidence, consensus statements and practice frameworks. There is limited systematic evidence. AREAS OF CONTROVERSY: We illustrate UK practice with clinical cases and describe worldwide variations. GROWING POINTS: Neonatal end-of-life care incorporating withholding and withdrawing intensive care is not uncommon. The child's 'best interests' take precedent and clinical guidance has been published to support the joint decision-making partnership of clinicians and families. Withholding and withdrawing intensive care should be part of an overall end-of-life care plan incorporating the principles and standards of palliative care. AREAS TIMELY FOR DEVELOPING RESEARCH: Further guidance on standards and staff training with regard to communicating and delivering neonatal end-of-life care is required to ensure consistent practice of staff and choices for families. The recommended establishment of neonatal outcome databases should aid UK preterm decision-making (NHS and Department of Health Neonatal Taskforce, Toolkit for high-quality neonatal services, London, Department of Health 2009).

A clinical information system reduces medication errors in paediatric intensive care.

PURPOSE: To determine the effect of electronic prescribing (EP) with a clinical information system (Intellivue Clinical Information Portfolio, Philips, UK) on prescribing errors and omitted doses in a paediatric intensive care unit (PICU). METHODS: Prospective audit of prescribing errors and omitted doses for 96 h periods in three epochs: (1) before implementation of EP, (2) 1 week and (3) 6 months later. RESULTS: There was a non-significant reduction in prescribing errors: 8.8% (95% CI 4.4-13.2) pre-implementation of EP versus 8.1% (4.4-11.8) 1 week after implementation and 4.6% (2.0-7.2) 6 months later. The prevalence of omitted doses decreased significantly 6 months following implementation, changing from 8.1% (5.8-10.4) pre-implementation to 10.6% (6.5-14.7) 1 week after implementation and 1.4% (CI 0-2.8%) 6 months after implementation (P < 0.05). CONCLUSION: EP within a clinical information system increases medication safety in a PICU.