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Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study

Journal of Perinatology volume 42, pages 1312–1318 (2022)Cite this article

Subjects

Abstract

Objective

To determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients.

Study design

We conducted a retrospective cohort study of 600 consecutive inborn admissions. A physician used the “Safer Dx NICU Instrument” to review the electronic health record for the first 7 days of admission, and categorized cases as “yes,” “unclear,” or “no” for diagnostic error. A secondary reviewer evaluated all “yes” charts plus a random sample of charts in the other categories. Subsequently, all secondary reviewers reviewed records with discordance between primary and secondary review to arrive at consensus.

Results

We identified 37 diagnostic errors (6.2% of study patients) with “substantial agreement” between reviewers (κ = 0.66). The most common diagnostic process breakdown was missed maternal history (51%).

Conclusion

The frequency of diagnostic error in inborn NICU patients during the first 7 days of admission is 6.2%.

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Fig. 1: Algorithm for chart review.

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Data availability

Data available on request due to privacy/ethical restrictions.

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Acknowledgements

We would like to thank Dr. Joseph Garcia-Prats, Dr. Mohan Pammi, and Dr. Lakshmi Katakam for their assistance with the secondary review process. The authors would also like to thank Dr. Joseph Hagan for his assistance with the statistical analysis.

Funding

This study was funded by the “Evie” Whitlock Fund for neonatal-perinatal medicine fellows at Baylor College of Medicine and Texas Children’s Hospital. Dr. Singh is funded in part by the Houston Veterans Administration (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness, and Safety (CIN13–413), the VA HSR&D Service (CRE17–127 and the Presidential Early Career Award for Scientists and Engineers USA 14–274), the VA National Center for Patient Safety, the Agency for Healthcare Research and Quality (R01HS27363), and the Gordon and Betty Moore Foundation. Dr. Thomas is supported by the University of Texas at Houston – Memorial Hermann Center for Healthcare Quality and Safety.

Author information

Authors and Affiliations

  1. Children’s Hospital of Orange County, Orange, CA, USA

    Grant J. Shafer

  2. University of California, Irvine School of Medicine, Irvine, CA, USA

    Grant J. Shafer

  3. Baylor College of Medicine, Houston, TX, USA

    Hardeep Singh & Satid Thammasitboon

  4. Michael E. Debakey VA Medical Center, Houston, TX, USA

    Hardeep Singh

  5. McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA

    Eric J. Thomas

  6. UT Houston-Memorial Hermann Center for Healthcare Quality and Safety, Houston, TX, USA

    Eric J. Thomas

  7. Center for Research, Innovation and Scholarship in Medical Education, Houston, TX, USA

    Satid Thammasitboon

  8. University of Central Florida College of Medicine, Orlando, FL, USA

    Kanekal Suresh Gautham

  9. Nemours Children’s Hospital, Orlando, FL, USA

    Kanekal Suresh Gautham

Authors
  1. Grant J. Shafer
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  2. Hardeep Singh
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  4. Satid Thammasitboon
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  5. Kanekal Suresh Gautham
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Contributions

GJS conceptualized and designed the study, designed the data collection tool and manual of operations, collected the data, performed the initial record review, carried out the initial analysis, drafted the initial manuscript, and reviewed and revised the manuscript. KSG conceptualized and designed the study, designed the data collection tool and manual of operations, and reviewed and revised the manuscript. HS conceptualized and designed the study, designed the original Safer Dx Instrument, and reviewed and revised the manuscript. EJT and ST conceptualized and designed the study, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Grant J. Shafer.

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The authors declare no competing interests.

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Shafer, G.J., Singh, H., Thomas, E.J. et al. Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study. J Perinatol 42, 1312–1318 (2022). https://doi.org/10.1038/s41372-022-01359-9

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