Background: Diagnostic errors in medicine represent a large source of preventable morbidity and mortality in hospitalized patients. Intensive care unit (ICU) patients may be at particularly high risk for misdiagnosis. Little is known about diagnostic error in pediatrics and even less is known about diagnostic error in the pediatric ICU (PICU).
Methods: Objective─ Estimate the frequency, severity, and principal causes of diagnostic error in PICU patients. Design ─ Systematic review of observational studies. Electronic (MEDLINE, EMBASE) and manual (references of eligible articles) search for articles. Terms (MeSH and Emtree) used included ICU, critical care, intensive care, pediatric; AND diagnostic error, misdiagnosis, diagnostic delay, diagnostic error; AND necropsy, autopsy. Inclusions ─ Studies of 10 or more patients who died in PICUs with diagnostic errors confirmed by autopsy were included. Two independent reviewers selected studies for inclusion, with differences adjudicated by a third. Patient characteristics, diagnostic error description and error classes (using standard Goldman criteria for autopsy misdiagnoses) were abstracted. Differences were resolved by consensus.
Results: We examined 202 citations and reviewed 76 articles. Six studies were included. Principal reasons for exclusions were lack of original data, lack of ICU-specific data, lack of pediatric data, and fewer than 10 patients reported. The six studies reported on diagnostic errors in 359 autopsies performed out of 810 PICU deaths (autopsy rate 44%). Goldman Class I diagnostic errors (major, likely lethal) were identified in 29 cases (8.1%) with a wide range of diagnoses missed, with the most frequent related to infection (41%). Class II diagnostic errors (major, likely non-lethal) were identified in 60 cases (17%), with the most frequent again related to infection (45%). Minor (Class III and IV) diagnostic errors were identified in 140 cases (39%).
Conclusion: Reported data on diagnostic error in PICU patients are limited. Available data suggest that major diagnostic errors (Class I or II error) occur in roughly 25% of autopsied PICU deaths. It is uncertain whether autopsy data over- or underestimate the frequency or severity of diagnostic errors, but the most frequent major diagnostic errors appear related to misdiagnosed infections. Further research is needed to better quantify pediatric and PICU-related diagnostic errors and to define potential strategies to reduce their frequency or mitigate misdiagnosis-related harm.
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