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Use of e-triggers to identify diagnostic errors in the paediatric ED
  1. Daniel Lam1,
  2. Fidelity Dominguez2,
  3. Jan Leonard3,
  4. Alexandria Wiersma3,
  5. Joseph A Grubenhoff3
  1. 1Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  2. 2Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
  3. 3Section of Pediatric Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  1. Correspondence to Dr Daniel Lam, Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA; daniel.lam{at}childrenscolorado.org

Abstract

Background Diagnostic errors (DxEs) are an understudied source of patient harm in children rarely captured in current adverse event reporting systems. Applying electronic triggers (e-triggers) to electronic health records shows promise in identifying DxEs but has not been used in the emergency department (ED) setting.

Objectives To assess the performance of an e-trigger and subsequent manual screening for identifying probable DxEs among children with unplanned admission following a prior ED visit and to compare performance to existing incident reporting systems.

Design/methods Retrospective single-centre cohort study of children ages 0–22 admitted within 14 days of a previous ED visit between 1 January 2018 and 31 December 2019. Subjects were identified by e-trigger, screened to identify cases where index visit and hospital discharge diagnoses were potentially related but pathophysiologically distinct, and then these screened-in cases were reviewed for DxE using the SaferDx Instrument. Cases of DxE identified by e-trigger were cross-referenced against existing institutional incident reporting systems.

Results An e-trigger identified 1915 unplanned admissions (7.7% of 24 849 total admissions) with a preceding index visit. 453 (23.7%) were screened in and underwent review using SaferDx. 92 cases were classified as likely DxEs, representing 0.4% of all hospital admissions, 4.8% among those selected by e-trigger and 20.3% among those screened in for review. Half of cases were reviewed by two reviewers using SaferDx with substantial inter-rater reliability (Cohen’s κ=0.65 (95% CI 0.54 to 0.75)). Six (6.5%) cases had been reported elsewhere: two to the hospital’s incident reporting system and five to the ED case review team (one reported to both).

Conclusion An e-trigger coupled with manual screening enriched a cohort of patients at risk for DxEs. Fewer than 10% of DxEs were identified through existing surveillance systems, suggesting that they miss a large proportion of DxEs. Further study is required to identify specific clinical presentations at risk of DxEs.

  • diagnostic errors
  • adverse events, epidemiology and detection
  • emergency department
  • incident reporting
  • paediatrics

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information. The data for this study are not available publicly as they are owned by Children’s Hospital Colorado, contain sensitive patient information, and could be used for medico-legal litigation.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information. The data for this study are not available publicly as they are owned by Children’s Hospital Colorado, contain sensitive patient information, and could be used for medico-legal litigation.

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Footnotes

  • Contributors JAG conceived and designed the study, obtained IRB approval, assisted with data acquisition, results interpretation and critically revised the manuscript. DL assisted with data acquisition, results interpretation, drafted the initial and revised manuscript and is guarantor for this work. JL aided in study design conducted the statistical analysis, drafted the statistics portion of the Methods and critically revised the manuscript. AW assisted with data acquisition and critically revised the manuscript. FD assisted with study design, provided critical oversight in the conduct of the study, aided with data acquisition and critically revised the manuscript.

  • Funding This study was funded by Colorado Clinical and Translational Sciences Institute (CTSA Grant UL1 TR002535).

  • Competing interests None declared.

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

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