Objective To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors.Study design A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors.Results From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification.Conclusions A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors.
BackgroundPediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months.MethodsWe reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July–December 2017; 101 charts were reviewed post-intervention, January–June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a ‘complete’ DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric.ResultsAt baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a ‘complete’ DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41–2.47, p = 0.73), but attending-documented DDx did not improve (2.85–2.82, p = 0.88).ConclusionsWe demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.
Introduction: Pediatric patients undergoing outpatient surgeries often receive prescriptions for postoperative pain, including opioid medications. As a result, the American Academy of Pediatrics formally challenged all pediatric surgeons to decrease opioid prescribing for common specialty-specific outpatient procedures at discharge. To meet this challenge, we designed a quality improvement project to decrease the average number of opioid doses administered to pediatric patients undergoing 3 common outpatient urologic surgeries: circumcision, orchiopexy, and inguinal hernia repair (IHR). Methods: We formally challenged providers at our institution to reduce opioid doses per prescription and administration to patients overall. We performed a retrospective chart review at our single pediatric institution to establish baseline opioid prescribing values from July 2017 to March 2018. We aimed to reduce this value by 50% in 6 months and sustain this decrease throughout the project duration. Results: We performed 1,518 orchiopexies, 1,505 circumcisions, and 531 IHRs. The percent change in the average number of opioid doses prescribed per patient from baseline values assessed to 2021 was statistically significant for orchiopexies (P < 0.0001), IHRs (P < 0.0001), and circumcisions (P < 0.0001). In addition, the change in the percentage of patients prescribed opioids from baseline was statistically significant for all 3 procedures (P < 0.001). Conclusions: This project demonstrated that through an organized quality improvement initiative, the average number of opioid medications prescribed and the total percentage of patients prescribed opioids following common outpatient pediatric urologic procedures can be decreased by at least 50% and sustained through project duration.
Results Mean delta weight Z-score increased from À1.8 to À1.08 (figure 4) following the implementation of all of the noted interventions with centerline shift that has lasted for 8 months (40% improvement). Mean number of lactation consults ordered per week increased from 1 to 4. Conclusions Reducing nutrition practice variation shows marked improvements in infant nutrition status. We continue to test other interventions with the hope of further decreasing growth failure.
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