Thank you for highlighting this infographic. I read the Contemporary Pediatrics related article by Drs. Selbst and Krill (Medical errors in the pediatric emergency department: Don't make these mistakes! 12-10-20. Contemporary PEDS Journal, Vol 37 No 12). They provide several cases that highlight some of the challenges of any high-acuity, low-information density environment. In my own practice and thinking about my environment from the perspective of diagnostic safety, there are a few others that are worth mentioning with an eye toward combating diagnostic errors.
Interestingly, in a simulated environment, distractions did not seem to significantly impact the diagnostic accuracy of practicing EM physicians and residents – errors were related more to experience and knowledge (Montiero S, et al. Disrupting Diagnostic Reasoning: Do Interruptions, Instructions, and Experience Affect the Diagnostic Accuracy and Response Time of Residents and Emergency Physicians? Academic Medicine, Vol. 90, No. 4 / April 2015)
Luckily there is a growing interest in diagnostic safety in pediatric hospitals and among academic pediatricians – we're just a little late to the game compared to some of our adult colleagues.
Great topic for discussion.
Joe Grubenhoff, MD, MSCS (he/him/his) | Associate Professor of Pediatrics
Section of Emergency Medicine | University of Colorado
Medical Director – Diagnostic Safety Program
Children's Hospital Colorado
13123 East 16th Avenue, Box 251 | Anschutz Medical Campus | Aurora, CO 80045 | Phone: (303) 724-2581 | Fax: (720) 777-7317
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I am guilty of this – whether premature closure or failure to unpack or diagnosis momentum – as an ED physician. Fortunately, I made a different dispo decision than the ED doc in the story you shared.
I cared for a teen with a history of PTSD who had been admitted not once but twice for lower extremity weakness. After an LP, MRI, neurology and psychiatry consultations and input from physical therapy, the team was convinced the patient had a conversion disorder; Guillain-Barre was considered ruled out. The teen presented to me with inability ("refusal" per the referring facility) to get out of bed even to toilet. Despite the complaints of dyspnea, inability to tolerate secretions requiring suction and absent patellar deep tendon reflexes, I admitted to general peds with a diagnosis of conversion disorder. It wasn't until days later when the patient developed supraventricular tachycardia (still not sure why) and had a repeat LP in the PICU did the spinal fluid show signs typical of Guillain Barre. The patient recovered. This happened to me AFTER I started my role in our diagnostic safety program.
There is a tendency to think that, if we as diagnosticians have done what we view as a thorough work-up, there is nothing left to be found (search satisfying) and ignore new information as it comes to light (anchoring). Too often we place our confidence in test results rather than what the patient tells us (in history and exam). If I had ignored the primacy of information from my colleagues and the tests and started from scratch, I might not have missed the diagnosis. I fell victim to #s 3 and 4 on my list.