Deciphering Diagnostic Errors in Pediatrics

Dr. Madan Roy 
Interim Regional Chief of Pediatrics,
Niagara Health Services
Deputy Chief, Department of Pediatrics
McMaster University
Chief, Division of General Pediatrics
McMaster Children's Hospital

Dr. Samara Chitayat 
Assistant Clinical Professor, Department of Pediatrics
McMaster University

It will be helpful to watch the video clip below, prior to reading the blog post. The video illustrates the case of Jessica Barnett, a 17 year old with a missed diagnosis of Long QT syndrome. Reviewing some key points of her story can helps us learn and understand some valuable points on diagnostic errors.

"Do No Harm: Jess' Story": 

A diagnostic error may be defined as a missed, inaccurate or delayed diagnosis. In a recent publication, the Institute of Medicine (IOM) also included failure to effectively communicate the diagnosis to the patient, in its definition. (1) Diagnostic errors are generally more difficult to identify and comprehend than other types of errors, and are understudied. (2) A study from the Journal of Pediatrics revealed meningitis, appendicitis, specified non-teratogenic anomalies, pneumonia, followed by brain-damaged infant, as the most prevalent conditions in pediatric malpractice claims caused by error in diagnosis in the United States. (3) A multisite survey by Singh et al. demonstrated that 54% of pediatricians surveyed reported making a diagnostic error at least once or twice per month, and 45% reported making diagnostic errors that caused harm to patients, once or twice per year. Viral illness being misdiagnosed as bacterial illness was perceived as the most frequent diagnostic error. (4)

The path towards making a patient diagnosis in pediatrics is composed of a series of steps: First, a patient experiences a health concern, and presents to medical attention. Second, the patient and their family engages with one or more medical professionals where history taking, physical examination, investigations, differential diagnoses, and sometimes referrals are made to collect the necessary information for synthesis of a diagnosis. Third, the diagnosis is relayed to the patient and their family, so that necessary treatment and follow-up can be instituted. (4) Each step of this diagnostic journey is vulnerable to error. Given the increasing complexity of the growing number of pediatric chronic care patients, diagnosis becomes even more increasingly challenging.

Errors in diagnosis can be caused by failures in one, or sometimes multiple areas that we can refer to as the 5 Cs of Diagnostic Downfalls:

- Collaboration and Communication
Primary care physicians, specialists, nurses, and allied health care, often collaborate as a team when diagnosing and treating patients. Holding case conferences and ensuring effective written communication can facilitate information sharing between key members. In pediatrics, family members of the patient are an important part of the diagnostic team, as they often help to identify signs and symptoms of illness. In Jessica's case, family members had raised the diagnosis of Long QT on several occasions, but felt that their concerns had been dismissed.

- Community Systems
Failure to have a system in place to follow-up test results in a timely and organized fashion, trouble with staffing or equipment, as well as flaws in policies and procedures, may all lead to failure of a community system. Systemic errors played a role in Jessica's case - examples include misplaced paper work, as well as a Cardiac Holter exam being read late.

- Clinician's Collection of data
If a resident or medical student has been involved with the patient's assessment, have they been adequately supervised? Has the necessary data been collected and correctly interpreted for synthesis of a diagnosis? The CMPA's "Good Practice Guide" (5) provides simple tips to avoid common pitfalls. Had some of Jessica's ECGs been read accurately, would a diagnosis of Long QT Syndrome have been made?

- Cognitive biases
Heuristics are short cuts that we use based on pattern recognition. When these are incorrectly applied, they may lead to errors that can be further classified according to types of cognitive biases. (6) "Anchoring" is an example of a cognitive bias that refers to human tendency to rely on the initial diagnostic impression when making a diagnosis. (6) In Jessica's case, the initial diagnostic impression was that of epilepsy. Thus, when new information presented to the contrary, it was dismissed. "Framing effects" is another type of cognitive bias, where the diagnosis made by the initial physician may impact subsequent assessments from occurring in an objective manner. (7) In Jessica's case, the neurologist may have influenced the cardiologist's assessment by suggesting in his consult request letter that she did not have Long QT.

- Culture
In order to learn from our errors and near misses, we need to create a safe environment where they can be reported, discussed, and learning points disseminated. Failure to achieve such a culture, creates a closed environment where sharing does not occur. From sharing cases like Jessica's, we hope that similar pitfalls are not encountered.

As in any improvement endeavour, achieving the goal of reducing/eliminating diagnostic errors starts with recognizing and understanding the scope of the problem. The healthcare providers and the systems we work in must accept that there are targeted measures we can take to achieve a significant reduction in diagnostic errors. Work by the IOM, Dr. Graber, Dr. Croskerry and a host of others have successfully highlighted the intensity and scope of harm from diagnostic errors and brought this to the forefront (8, 9). With acceptance and awareness comes the ability to change one's own cognition and biases, as well as the ability to look at and improve processes and systems.

The approach to preventing diagnostic errors is multipronged. Systems changes, attitude and awareness of individual healthcare providers, education, partnerships with patients and families and newer technologies will all play important roles in reducing diagnostic errors.

Physicians and healthcare providers will need to focus on maintaining a constant state of cognitive alertness to ensure proper data collection, critical reasoning, creating a differential diagnosis and type 2 thinking, with awareness of their own biases and vulnerability to environmental factors that disrupt logical thinking. They will need to make their patients, children and their parents, partners with them in the diagnostic process. This team effort will prevent communication errors, ensure transparency, build trust and lead to a more wholesome approach that will likely lead to a reduction in errors in the diagnostic process. Diagnostic error checklists, feedback to providers regarding diagnostic errors made with the reasons for the error, and simulation training geared at teaching providers how errors happen and how they can be avoided, will all play a critical role in individuals improving their diagnostic reasoning skills.

Systems improvements will largely be technology led through EMRs that speak with each other and seamlessly connect with all providers, patients, laboratories, and pharmacies. Updated evidence-based practice guidelines that are readily accessible are also vital. In the not too distant future IBM's Watson or other specialized pediatric artificial intelligence software embedded within these EMRs (e.g. 'Isabel Active Intelligence' fully EMR embedded diagnosis decision support system) will become the norm, and prompt us towards the correct diagnosis. The healthcare system as a whole will ensure compensation models that credit systems and providers who focus on improved diagnostic accuracy, thus allowing providers and systems the ability to focus on improvements in diagnostic error prevention.

1. Improving Diagnosis in Health Care, Quality Chasm Series, Institute of Medicine, September 2015. A link to this summary can be found at:
2. Improving Diagnosis in Health Care – The Next Imperative for Patient Safety, The New England Journal of Medicine, Hardeep Singh, Mark L. Graber, November 11th 2015,
3. Medical Diagnoses Commonly Associated with Pediatric Malpractice Lawsuits in the United States, Gary N. McAbee et al, Pediatrics 2008;122;e1282-e1286.
4. Errors of Diagnosis in Pediatric Practice: A Multisite Survey, Hardeep Singh et al, Pediatrics 2010;126;70.
5. CMPA Good Practice Guide: Diagnostic Tips from the CMPA’s Experience. Link to this guide can be found at:
6. Diagnostic Errors, AHRQ Patient Safety Network, August 2014. A link to this article can be found at:
7. Cognitive Bias in Inpatient Pediatrics, Adam Berkwitt, Matthew Grossman, Hospital Pediatrics, Volume 4, Issue 3, 190-193.
8. Diagnostic Failure: A Cognitive and Affective Approach, Pat Croskerry, Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology), 241-254.
9. Checklists to Reduce Diagnostic Errors, John Ely, Mark Graber, Pat Croskerry, Academic Medicine, Volume 86(3), March 2011, pp 307-313.

Related Links:
1. AAP - Wave 2 Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!)
2. ACP Hospitalist - Next patient safety target: misdiagnosis - how hospitalists can help reduce diagnostic error
3. ACS National Surgical Quality Improvement Program (NSQIP) Pediatric
4. AHC Media - Addressing the problem of diagnostic errors
5. AHRQ - Outpatient Diagnostic Errors Affect 1 in 20 U.S. Adults, AHRQ Study Finds
6. AHRQ - Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care
7. AHRQ - Understanding and Improving Diagnostic Safety in Ambulatory Care
8. AHRQ PSNet - Patient Safety Primers - Diagnostic Errors
9. Ambient Clinical Analytics - Mayo Clinic and Tech Entrepreneurs Join Forces to Launch Ambient Clinical Analytics, First-Ever Bedside Decision Support Platform to Transform Patient Critical Care
10. Ambiant Clinical Analytics - Solutions
11. AMN Healthcare - Diagnostic Errors Common and Preventable: 1 in 20 Missed
12. Armstrong Institute - Ruling Out the Wrong Diagnosis
13. ARUP - Diagnostic Error and Laboratory Testing
14. Atlantic - Why it's so easy for doctors to misdiagnose kids
15. Business Insider - IBM's Watson Supercomputer May Soon Be The Best Doctor In The World
16. CAPHC - CAPHC Paediatric Sepsis Screening Tool
17. Children's Hospital of Philadelphia (CHOP) - Clinical Pathways
18. Children's Hospitals' Solutions for Patient Safety (SPS) - Hospital Resources
19. Choosing Wisely - AAP - Ten Things Physicians and Patients Should Question
20. Cincinnati Children's - Rapid Evidence Adoption to improve Child Health (REACH)
21. Clarity Informatics UK - Quality Improvement Service - Case Study: North West England, Advancing Quality
22. CMPA - Diagnostic Process
23. CMPA - Diagnostic Tips
24. CRICO - 2014 CBS Report: Malpractice Risks in the Diagnostic Process
25. CRICO - CRICO Strategies Shares Comparative Medical Malpractice Data for Research and Publication
26. CRICO - CRICO's 12-Step Diagnostic Process of Care Framework
27. CRICO - Figuring Out Diagnostic Errors
28. CRICO - How Do Diagnosis Errors Happen? New National Report Sheds Light
29. CRICO - Malpractice Risks in the Diagnostic Process
30. CRICO - Obamacare & Malpractice
31. CRICO - Patient Safety - Diagnosis
32. CrowdMed (solves difficult medical cases online)
33. DXplain Decision Support System
34. GHDonline - Expert Panel: Diagnostic Error Reduction - Resources
35. Gizmag - IBM's Watson adapted to teach medical students and aid diagnosis
36. HARC - Reducing diagnostic error in medicine: What can I do?
37. IBM - IBM Research Unveils Two New Watson Related Projects from Cleveland Clinic Collaboration
38. IBM - Watson Health
39. IBM - Watson in Healthcare
40. IBM - WatsonPaths
41. IOM - Public Release of the Report of the Committee on Diagnostic Error in Health Care
42. ISABEL (web-based, Diagnosis Checklist System) - About ISABEL
43. ISABEL - Diagnostic Errors
44. ISABEL - Isabel Healthcare Announces 'Isabel Active Intelligence' - the World’s First Fully EMR Embedded Diagnosis Decision Support System
45. ISABEL - Minimizing Diagnostic Error: 10 Things you can do tomorrow
46. KevinMD - Diagnostic Errors and Their Role in Patient Safety
47. Making it Safer Together (MiST) paediatric patient safety collaborative
48. MedPageToday - Diagnosis Error Is Costliest Medical Mistake
49. Modern Healthcare - Physicians blame patient 'treadmill' for missed calls
50. National Pediatric Readiness Project (PRP) (ensuring emergency care for all children) - Readiness Toolkit
51. NYT - An Infection, Unnoticed, Turns Unstoppable
52. NYT - Small patients, big consequences in medical errors 
53. NPSF - AAP Innovative Outpatient Pediatric Diagnostic Error Quality Improvement Project Now Recruiting
54. NPSF - Checklist for Getting the Right Diagnosis
55. NPSF - Diagnostic Error Prevention - General Resources
56. NPSF - E-learning - Reducing Diagnostic Errors
57. NPSF - Preventing Diagnostic Error Resource List
58. OPENPediatrics - Resources
59. Pediatric Standardized Clinical Assessment and Management Plans (SCAMPs)
60. Partnership for Patients (PfP) - Pediatric Safety
61. PR Newswire - Zynx Health Announces Innovative Line of Analytic Clinical Improvement Solutions
62. PRWeb - Isabel Healthcare Announces 'Isabel Active Intelligence' - the World's First Fully EMR Embedded Diagnosis Decision Support System
63. PIPSQC Presentations - Building on Parent's Concerns - Improving Safety and Decreasing Diagnostic Error 
64. PIPSQC Presentations - Challenging the Issues of Missed and Delayed Diagnosis
65. Project Jessica - 25 Tips to Help Protect Yourself from Medical Errors
66. Risky Business - Walking a tightrope balancing standardization of care with minimizing cognitive bias
67. Seattle Children's - Clinical Standard Work Pathways and Tools
68. Society to Improve Diagnosis in Medicine (SIDM) - Educational Resources
69. SIDM - Diagnostic Error Measures Worksheet
70. SIDM - Diagnostic Error Resources
71. SIDM - Preventing Diagnostic Error: Where Do I Start?
72. SIDM - Preventing Diagnostic Error: Where Do I Start? webcast slides
73. SIDM - Reducing Diagnostic Error - Ambulatory Practices - Ten Things I Could Do Tomorrow
74. SIDM - Reducing Diagnostic Error - Nurses and Clinical Staff - Ten Things I Could Do Tomorrow
75. SIDM - Reducing Diagnostic Error - Physicians, PAs, and NPs - Ten Things I Could Do Tomorrow
76. Situation Awareness for Everyone (SAFE)
77. Time - Diagnostic Errors Are the Most Common Type of Medical Mistake
78. Today's Hospitalist - Wrong-diagnosis anonymous - A hospital takes on "the sleeping dog" of patient safety
79. U of Texas Health Science - Clinical Reasoning and Diagnostic Error
80. UK Sepsis Trust - Acute Paediatric Toolkit - Paediatric Sepsis 6
81. Wachter's World - Diagnostic Errors: Central to Patient Safety, Yet Still In the Periphery of Safety's Radar Screen
82. Wachter's World - Why Diagnostic Errors Don't Get Any Respect... And What Can Be Done About It
83. WSJ - Battle Against Misdiagnosis: American doctors make the wrong call more than 12 million times a year
84. WSJ - IBM Crafts a Role for Artificial Intelligence in Medicine
85. WSJ - Preventing the tragedy of misdiagnosis
86. WSJ - What if the doctor is wrong?
87. Zynx Health - Solutions

Related Publications:
1. 25-Year summary of US malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank
2. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework
3. Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study
4. An Interview with Dr. Mark Graber
5. Annual Perspective 2014: Diagnostic Errors
6. Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study
7. Bringing Diagnosis Into the Quality and Safety Equations
8. Challenges in defining and measuring diagnostic error
9. Changes in Medical Errors after Implementation of a Handoff Program
10. Checklists to prevent diagnostic errors: a pilot randomized controlled trial
11. Cognitive Bias in Inpatient Pediatrics
12. Cognitive interventions to reduce diagnostic error: a narrative review
13. Collective intelligence meets medical decision-making: the collective outperforms the best radiologist
14. Combination Protocol Accurately Diagnoses Appendicitis in Kids
15. Commentary: How Can We Make Diagnosis Safer?
16. Common patterns in 558 diagnostic radiology errors
17. Crowdsourcing Diagnosis for Patients With Undiagnosed Illnesses: An Evaluation of CrowdMed
18. Detection of missed injuries in a pediatric trauma center with the addition of acute care pediatric nurse practitioners
19. Diagnosing diagnostic error
20. Diagnosis (Volume 1, Issue 1)
21. Diagnosis: A new era, a new journal
22. Diagnosis and High Reliability
23. Diagnostic accuracy of paediatric echocardiograms interpreted by individuals other than paediatric cardiologists
24. Diagnostic decision-making and strategies to improve diagnosis
25. Diagnostic delays in paediatric stroke
26. Diagnostic difficulty and error in primary care - a systematic review
27. Diagnostic error in children presenting with acute medical illness to a community hospital
28. Diagnostic Error in Medicine (Special Issue)
29. Diagnostic error in medicine: analysis of 583 physician-reported errors
30. Diagnostic Errors and Strategies to Minimize Them (Special Issue)
31. Diagnostic errors in congenital echocardiography: importance of study conditions
32. Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors
33. Diagnostic errors in pediatric radiology
34. Diagnostic Errors in the Pediatric and Neonatal ICU: A Systematic Review
35. Diagnostic errors: moving beyond 'no respect' and getting ready for prime time
36. Diagnostic Errors - The Next Frontier for Patient Safety
37. Diagnostic Failure: A Cognitive and Affective Approach
38. Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making
39. Digitizing diagnosis: a review of mobile applications in the diagnostic process
40. Editorial: Helping Health Care Organizations to Define Diagnostic Errors as Missed Opportunities in Diagnosis
41. Editorial: Helping Organizations with Defining Diagnostic Errors as Missed Opportunities in Diagnosis
42. Educational agenda for diagnostic error reduction
43. Educational strategies for improving clinical reasoning
44. Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centers
45. Errors of diagnosis in pediatric practice: a multisite survey
46. "First, know thyself": cognition and error in medicine
47. Foreword for diagnostic errors and how to improve them
48. Frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations
49. From To Err Is Human to Improving Diagnosis in Health Care: the risk management perspective
50. Graphical display of diagnostic test results in electronic health records: a comparison of 8 systems
51. How well do health professionals interpret diagnostic information? A systematic review
52. Impact of a Web-based diagnosis reminder system on errors of diagnosis
53. Improving Diagnosis in Health Care - IOM Report at a Glance
54. Improving Diagnosis in Health Care - The Next Imperative for Patient Safety
55. Incidence of diagnostic error in medicine
56. Initial diagnostic errors in children suspected of having heart disease: prevalence and long-term consequences
57. International assessment of a web-based diagnostic tool in critically ill children
58. Learning from common diagnostic errors: A case review
59. Learning from Errors in Ambulatory Pediatrics
60. Malpractice Claims Involving Pediatricians: Epidemiology and Etiology
61. Measurement of Diagnostic Errors Is a Key First Step to Their Reduction
62. Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States
63. Misdiagnosis of acute cervical spine injuries and fractures in infants and children: the 12-year experience of a level I pediatric and adult trauma center
64. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims
65. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims form 4 liability insurers
66. Missed diagnosis of critical congenital heart disease
67. Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care
68. Next Organizational Challenge: Finding and Addressing Diagnostic Error
69. Novel diagnostic aid (ISABEL): development and preliminary evaluation of clinical performance
70. Patient safety strategies targeted at diagnostic errors: a systematic review
71. Peer review comments augment diagnostic error characterization and departmental quality assurance: 1-year experience from a children's hospital 
72. Perspectives from a pediatrician about diagnostic errors
73. Perspectives on Diagnostic Failure and Patient Safety
74. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool
75. PS-120 Diagnostic Error In Paediatrics - A National Survey
76. Reducing Diagnostic Errors - Why Now?
77. System-related factors contributing to diagnostic errors
78. System-related interventions to reduce diagnostic errors: a narrative review
79. Types and Origins of Diagnostic Errors in Primary Care Settings
80. Underdiagnosis of hypertension in children and adolescents
81. Use of a novel, modified fishbone diagram to analyze diagnostic errors
82. Using voluntary reports from physicians to learn from diagnostic errors in emergency medicine
83. Validating a decision tree for serious infection: diagnostic accuracy in acutely ill children in ambulatory care
84. Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service?
85. Why Diagnostic Errors Don’t Get Any Respect - And What Can Be Done About Them
86. Why physicians err in diagnosis