P0124 - Electronic triggers to study diagnostic errors in pediatric emergency departments

Background: Diagnostic errors, framed as missed opportunities for improving diagnosis (MOIDs), are a source of risk in pediatric emergency departments (EDs). We sought to identify triggers to screen ED records for diagnostic safety.

Objective: We pilot tested three electronic triggers (eT) to study frequency and contributory factors of diagnostic errors in pediatric EDs: 1) return visits within 10 days resulting in admission (eT1), 2) care escalation or transfer from in-patient unit to intensive care unit within 24 hours of ED presentation (eT2), and 3) death within 24 hours of ED visit (eT3).

Design/

Methods: We created a standardized electronic query and reporting template for the 3 eTs and applied them to electronic health record (EHR) systems of 5 pediatric EDs (Figure 1). We included all ED visits at each site for a single month for eT1 and eT2 and extended the period for eT3 for 12 months to yield enough cases for review. After testing for accuracy and face validity of abstracted EHRs, we trained 2 clinicians from each ED to review the triggered cases. Each reviewer manually screened the ED diagnoses at initial and return visits (eT1) and admitting diagnosis and final discharge diagnosis (eT2, eT3) and initially categorized charts as “unlikely for MOIDs” or “unable to rule out MOIDs” without a detailed chart review. For the latter category, reviewers performed a detailed chart review using the validated instrument, Safer Dx, to categorize as MOIDs or no MOIDs, dichotomized as a score ≥ 4 out of 7 on a Likert scale as suggestive of a MOID.

Results: Electronic queries identified 807 ED records, of which 52 (6.4%) were excluded after manual screen (Figure 2). 74% (559/755), 21% (156/755), and 5% (40/755) charts were triggered for eT1, eT2 and eT3 respectively. Among those, most records; 72.2% (404/559), 84% (131/156) and 95% (38/40) were categorized by the reviewers as unlikely for MOIDS. (Table 1) MOIDs was detected in 11.6% - 66.6% of eT1 and 16% - 100% for eT2 charts. The overall frequency of MOIDs in the e-triggered charts was 4.9% (37/755), 1.6% (12/755), and 0.13% (1/755) for eT1, eT2 and eT3 respectively.

Conclusions: We successfully pilot tested a methodology of using e-triggers and record review to screen large numbers of medical records to identify diagnostic errors in pediatric ED visits. Return visits with admission and transfer to higher level of care can be used as electronic triggers to screen for ED diagnostic errors while death within 24 hours does not appear to be useful.