Article Text

Download PDFPDF
Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments
  1. Kenneth A Michelson1,2,
  2. Finn L E McGarghan1,
  3. Emma E Patterson1,
  4. Margaret E Samuels-Kalow3,
  5. Mark L Waltzman1,2,
  6. Kimberly F Greco4
  1. 1 Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  2. 2 Department of Pediatrics, South Shore Hospital, Weymouth, Massachusetts, USA
  3. 3 Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  4. 4 Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Kenneth A Michelson, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA 02115, USA; kenneth.michelson{at}


Objective To evaluate rates, risk factors and outcomes of delayed diagnosis of seven serious paediatric conditions.

Methods This was a retrospective, cross-sectional study of children under 21 years old visiting 13 community and tertiary emergency departments (EDs) with appendicitis, bacterial meningitis, intussusception, mastoiditis, ovarian torsion, sepsis or testicular torsion. Delayed diagnosis was defined as having a previous ED encounter within 1 week in which the condition was present per case review. Patients with delayed diagnosis were each matched to four control patients without delay by condition, facility and age. Conditional logistic regression models evaluated risk factors of delay. Complications were compared between by delayed diagnosis status.

Results Among 14 972 children, delayed diagnosis occurred in 1.1% (range 0.3% for sepsis to 2.6% for ovarian torsion). Hispanic (matched OR 2.71, 95% CI 1.69 to 4.35) and non-Hispanic black (OR 2.40, 95% CI 1.21 to 4.79) race/ethnicity were associated with delayed diagnosis, whereas Asian and other race/ethnicity were not. Public (OR 2.21, 95% CI 1.42 to 3.44) and other (OR 2.43, 95% CI 1.50 to 3.93) insurance were also associated with delay. Non-English language was associated with delay (OR 1.65, 95% CI 1.02 to 2.69). Abnormal vital signs were associated with a lower likelihood of delay (OR 0.15, 95% CI 0.09 to 0.25). In an adjusted model, Hispanic race/ethnicity, other insurance, abnormal vital signs and complex chronic conditions (CCCs) were associated with delay. The odds of a complication were 2.5-fold (95% CI 1.6 to 3.8) higher among patients with a delay.

Conclusion Delayed diagnosis was uncommon across 13 regional EDs but was more likely among children with Hispanic ethnicity, CCCs or normal vital signs. Delays were associated with a higher risk of complications.

  • diagnostic errors
  • emergency department
  • paediatrics
  • patient safety
  • quality measurement

Data availability statement

Data are available upon reasonable request.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Data are available upon reasonable request.

View Full Text


  • X @markwaltzman

  • Contributors KAM was the guarantor of the study and contributed to study planning, data collection and data analysis, and drafted the manuscript. FLEM and EEP contributed to data collection and revised the manuscript. MES-K and MLW contributed to the study planning, data collection and manuscript revision. KFG contributed to the data analysis and revised the manuscript.

  • Funding This study was supported by CRICO/RMF.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.