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7 common causes of medical error in pediatric emergency medicine

  • 1.  7 common causes of medical error in pediatric emergency medicine

    Posted 28 days ago


  • 2.  RE: 7 common causes of medical error in pediatric emergency medicine

    Posted 27 days ago

    Helen,

    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.

     

    1. Decision-fatigue: The number and complexity of decisions made in the pediatric ED amplified by the potential risk of missing a critical illness or injury degrade decision-making over time. One study showed that even for the simple task of choosing whether to prescribe antibiotics for viral URIs diminishes in 4 hours (Linder JA, et al. Time of day and the decision to prescribe antibiotics. JAMA Intern Med. 2014 Dec;174(12):2029-31)
      1. Pat  Croskerry also writes about this (CJEM. 2014;16(1))
    2. Lack of Feedback: One of the key skills taught in pediatric (and general) emergency medicine training is safe disposition. Often that supersedes diagnostic accuracy in busy EDs. However, EM physicians infrequently get feedback on the outcomes related both to whether the disposition was actually safe or the diagnosis accurate and often only if the outcome is catastrophic, related to lawsuits or the dumb luck of being on shift when the patient returns. Overcoming this feedback sanction may be partially achieved by duration in practice but would be better served by systems designed to let EM physicians know what happened to their patients.
    3. Priming: Rarely are EM physicians first to see the patient. Triage acuity, which is only a first approximation, may cue an EM physician to dismiss a patient's complaints if the triage level is low or, alternatively, lead to overly aggressive evaluation (overdiagnosis) when the triage is inappropriately high. Additionally, other staff who may have already met the patient often make comments like "Tina is back again with chest pain" or "That kid's mom is over-reacting". These comments subconsciously lead to potentially minimizing the patient's complaints, not unpacking this episode compared to prior ones, or failing to follow typical ED diagnostic evaluation because the physician already assumes she will not find anything. We need to better understand how these factors influence our decision-making.
    4. A healthy population: Children are generally healthy and critical illness is far less common. Base-rate neglect, zebra retreat, availability bias and posterior probability errors (for frequent ED users) may lead us to assume the patient has a mild illness rather than a life-threatening emergency (dehydration vs myocarditis). Yet most kids seen in an ED do NOT need extensive evaluations. One major challenge for my general EM colleagues is the relatively low volume of pediatric cases in general EDs and less experience with nuanced pediatric presentations of critical illness. They must feel like I do when an adult inadvertently wanders into my ER – I don't feel confident in what I'm doing but EMTALA requires me to at least start an evaluation. At least I have the luxury of saying, I'm not qualified to treat adults and can transfer them to a place that can.

     

    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.

     

    signature_1232185625

    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

    joe.grubenhoff@childrenscolorado.org

    Connect with Children's Hospital Colorado on Facebook and Twitter

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    For a child's sake...

                    We are a caring community called to honor the sacred trust of our patients, families and each other through

                    humble expertise, generous service and boundless creativity.

    ...This is the moment.

     


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  • 3.  RE: 7 common causes of medical error in pediatric emergency medicine

    Posted 26 days ago
    Joe, thank you for filling in the details on this. These are common errors and I have certainly had reports of them in the pediatric population. Some of them are difficult for a person who is not in emergency medicine to comprehend.

    It's not just peds. Here is another example of what appears to be priming - accepting the earlier diagnosis without reassessing. Quoting the wife: "He said, 'ma'am, he's already been here twice for the same thing and we've already diagnosed him.'" This was a few minutes before the patient died in the hospital parking lot. I would love your thoughts on this. It strikes me as not entirely dissimilar to the Canadian case we were talking about a few days ago, in which a mentally ill patient who was suffering paralysis was not believed. Of course details are missing, but could this be just a different kind of bias?

    St. Peters father dies in hospital parking lot after family says hospital refused treatment






  • 4.  RE: 7 common causes of medical error in pediatric emergency medicine

    Posted 26 days ago

    Helen,

    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.

     

    signature_1232185625

    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

    joe.grubenhoff@childrenscolorado.org

    Connect with Children's Hospital Colorado on Facebook and Twitter

    signature_829143088

    For a child's sake...

                    We are a caring community called to honor the sacred trust of our patients, families and each other through

                    humble expertise, generous service and boundless creativity.

    ...This is the moment.

     


    CONFIDENTIALITY NOTICE:  This e-mail, including any attachments, is for the sole use of Childrens Hospital Colorado and the intended recipient(s). It may contain confidential and privileged information or may otherwise be protected by law. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message and any attachment thereto.