Research article

Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making

Padmanabhan Ramnarayan¹ , Andrew Winrow² , Michael Coren³ , Vasanta Nanduri⁴ , Roger Buchdahl⁵ , Benjamin Jacobs⁶ , Helen Fisher⁷ , Paul M Taylor⁸ , Jeremy C Wyatt⁹ and Joseph Britto⁷

¹  Children's Acute Transport Service (CATS), 44B Bedford Row, London, WC1H 4LL, UK

²  Department of Paediatrics, Kingston General Hospital, Galsworthy Road, Kingston-upon-Thames, KT2 7QB, UK

³  Department of Paediatrics, St Mary's Hospital, Paddington, London, W2 1NY, UK

⁴  Department of Paediatrics, Watford General Hospital, Vicarage Road, Watford, WD18 0HB, UK

⁵  Department of Paediatrics, Hillingdon Hospital, Pield Heath Road, Middlesex, UB8 3NN, UK

⁶  Department of Paediatrics, Northwick Park Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, UK

⁷  Isabel Healthcare Ltd, Po Box 244, Haslemere, Surrey, GU27 1WU, UK

⁸  Centre for Health Informatics and Multiprofessional Education (CHIME), Archway Campus, Highgate Hill, London, N19 5LW, UK

⁹  Health Informatics Centre, The Mackenzie Building, University of Dundee, Dundee, DD2 4BF, UK

author email corresponding author email

BMC Medical Informatics and Decision Making 2006, 6:37doi:10.1186/1472-6947-6-37

Published:	6 November 2006

Abstract

Background

Diagnostic error is a significant problem in specialities characterised by diagnostic uncertainty such as primary care, emergency medicine and paediatrics. Despite wide-spread availability, computerised aids have not been shown to significantly improve diagnostic decision-making in a real world environment, mainly due to the need for prolonged system consultation. In this study performed in the clinical environment, we used a Web-based diagnostic reminder system that provided rapid advice with free text data entry to examine its impact on clinicians' decisions in an acute paediatric setting during assessments characterised by diagnostic uncertainty.

Methods

Junior doctors working over a 5-month period at four paediatric ambulatory units consulted the Web-based diagnostic aid when they felt the need for diagnostic assistance. Subjects recorded their clinical decisions for patients (differential diagnosis, test-ordering and treatment) before and after system consultation. An expert panel of four paediatric consultants independently suggested clinically significant decisions indicating an appropriate and 'safe' assessment. The primary outcome measure was change in the proportion of 'unsafe' workups by subjects during patient assessment. A more sensitive evaluation of impact was performed using specific validated quality scores. Adverse effects of consultation on decision-making, as well as the additional time spent on system use were examined.

Results

Subjects attempted to access the diagnostic aid on 595 occasions during the study period (8.6% of all medical assessments); subjects examined diagnostic advice only in 177 episodes (30%). Senior House Officers at hospitals with greater number of available computer workstations in the clinical area were most likely to consult the system, especially out of working hours. Diagnostic workups construed as 'unsafe' occurred in 47/104 cases (45.2%); this reduced to 32.7% following system consultation (McNemar test, p < 0.001). Subjects' mean 'unsafe' workups per case decreased from 0.49 to 0.32 (p < 0.001). System advice prompted the clinician to consider the 'correct' diagnosis (established at discharge) during initial assessment in 3/104 patients. Median usage time was 1 min 38 sec (IQR 50 sec – 3 min 21 sec). Despite a modest increase in the number of diagnostic possibilities entertained by the clinician, no adverse effects were demonstrable on patient management following system use. Numerous technical barriers prevented subjects from accessing the diagnostic aid in the majority of eligible patients in whom they sought diagnostic assistance.

Conclusion

We have shown that junior doctors used a Web-based diagnostic reminder system during acute paediatric assessments to significantly improve the quality of their diagnostic workup and reduce diagnostic omission errors. These benefits were achieved without any adverse effects on patient management following a quick consultation.