Diagnostic Errors in a PICU: Insights From the Morbidity and Mortality Conference.
Pediatr Crit Care Med
; 16(5): 468-76, 2015 Jun.
Article
em En
| MEDLINE
| ID: mdl-25838150
ABSTRACT
OBJECTIVES:
To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process.DESIGN:
Retrospective record review of morbidity and mortality conference agendas, patient charts, and autopsy reports.SETTING:
Single tertiary referral PICU in Baltimore, MD. PATIENTS Ninety-six patients discussed at the PICU morbidity and mortality conference from November 2011 to December 2012.INTERVENTIONS:
None. MEASUREMENTS AND MAINRESULTS:
Eighty-nine of 96 patients (93%) discussed at the PICU morbidity and mortality conference had at least one identified safety event. A total of 377 safety events were identified. Twenty patients (21%) had identified misdiagnoses, comprising 5.3% of all safety events. Out of 20 total diagnostic errors identified, 35% were discovered at autopsy while 55% were reported primarily through the morbidity and mortality conference. Almost all diagnostic errors (95%) could have had an impact on patient survival or safety. Forty percent of errors did not cause actual patient harm, but 25% were severe enough to have potentially contributed to death (40% no harm vs 35% some harm vs 25% possibly contributed to death). Half of the diagnostic errors (50%) were rated as preventable. There were slightly more system-related factors (40%) solely contributing to diagnostic errors compared with cognitive factors (20%); however, 35% had both system and cognitive factors playing a role. Most errors involved vascular (35%) followed by neurologic (30%) events.CONCLUSIONS:
Diagnostic errors in the PICU are not uncommon and potentially cause patient harm. Most appear to be preventable by targeting both cognitive- and system-related contributing factors. Prospective studies are needed to further determine how and why diagnostic errors occur in the PICU and what interventions would likely be effective for prevention.
Texto completo:
1
Base de dados:
MEDLINE
Assunto principal:
Unidades de Terapia Intensiva Pediátrica
/
Erros de Diagnóstico
Tipo de estudo:
Diagnostic_studies
/
Observational_studies
/
Prognostic_studies
Limite:
Adolescent
/
Child
/
Child, preschool
/
Female
/
Humans
/
Infant
/
Male
Idioma:
En
Ano de publicação:
2015
Tipo de documento:
Article