For example, if incomplete anatomic or functional examination is found to be a significant contributor to errors assigned to quadrant A, a center may consider a change in practice to reduce the number of focused incomplete examinations. Moreover, a center may evaluate the root causes of performing a large number of focused examinations eg, the time allotted for the examination is too short and address those issues specifically. Another example is if a center finds that many errors occur because of incomplete clinical information. In that circumstance, evaluation of pre-examination procedures might reveal gaps in communication between referring physicians and the Echocardiography Laboratory, and steps can be taken to minimize such gaps.
Additionally, the finding that cognitive factors were the most common contributors to diagnostic errors in our laboratory suggests that our center should target educational initiatives designed to address areas of deficient knowledge in CHD anatomy and pathophysiology. Such initiatives should subsequently be monitored for evidence of reduction in errors related to cognitive factors. We identified both patient-related and situational risk factors for a diagnostic error. Lower patient weight has been previously reported as a risk factor for diagnostic errors, in agreement with our findings.
For example, we found that a number of the errors in studies performed in the recovery suite were due to poor image quality and incomplete examinations. This may suggest a time constraint, which leads to incomplete studies and greater risk for error. Complex cardiac anatomy is an intuitive risk factor for a diagnostic error.
Interestingly, although moderate anatomic complexity was a predictor for error, in the highest category of complexity only a trend existed toward having a diagnostic error. One possible explanation is that readers are more likely to seek a second opinion from an experienced colleague when faced with a highly complex case, whereas the likelihood of seeking consultation in moderately complex studies might be lower.
Another possible explanation is that the number of highly complex cases is not large enough to detect a statistically significant risk. Recognition of these risk factors may alert echocardiographers to have a higher index of suspicion for diagnostic errors. Selection bias and incomplete case ascertainment are notable limitations of this study.
The majority of cases were identified by a second imaging study or procedure. Patients without a second imaging study or procedure may have had a diagnostic error that was not identified. Therefore, the study likely underestimates the total number of diagnostic errors and is probably biased toward selecting errors with a greater clinical impact. Finally, the sample size limits the statistical power for subgroup analysis. A diagnostic error taxonomy and knowledge of risk factors can assist in the identification of targets for quality improvement initiatives that aim to reduce diagnostic errors in pediatric echocardiography.
This report represents a first step toward the development of methods to improve the quality of diagnostic imaging for CHD. Echocardiography is the first line of investigation among patients with congenital heart disease; timely treatment depends on accurate diagnosis.
Step by Step Pediatric Echocardiography
Inaccurate diagnoses place children with congenital heart disease at risk for adverse outcomes. Multivariate analysis identified the following risk factors for preventable or possibly preventable echocardiography diagnostic errors: A diagnostic error taxonomy and knowledge of risk factors can assist in identifying and prioritizing targets for quality improvement initiatives that aim to decrease diagnostic error in pediatric echocardiography. This work was supported by the National Institutes of Health under award number: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
National Center for Biotechnology Information , U. Author manuscript; available in PMC Nov The publisher's final edited version of this article is available at Circulation.
Pediatric Echocardiography on the App Store
See other articles in PMC that cite the published article. Abstract Background Despite increased interest in complications within pediatric cardiology, the domain of imaging-related diagnostic errors has received little attention. Methods and Results Diagnostic errors were identified at a high-volume academic pediatric cardiac center from December to August Conclusions A diagnostic error taxonomy and knowledge of risk factors can assist in identification of targets for quality improvement initiatives that aim to decrease diagnostic error in pediatric echocardiography.
Introduction Congenital heart disease CHD is among the most prevalent malformations among infants and is the leading cause of death from congenital malformations. Diagnostic Error Case Ascertainment Since December , as part of a quality improvement initiative in the Noninvasive Cardiology Division, data related to diagnostic error cases were collected prospectively through a voluntary reporting mechanism and active quality assurance mechanisms. Data Collected The following patient demographic and case data were collected: Diagnostic Error Case Review Process Diagnostic error cases were reviewed by staff pediatric echocardiographers, including review of medical records and other diagnostic images in addition to the images of the study in question.
Diagnostic Error Categorization False Negative A false negative is an error that omits a finding or states that a finding is normal or absent when an abnormality is present or the reader failed to include a significant diagnostic possibility; eg, patent ductus arteriosus is ruled out or omitted when a patent ductus arteriosus is present. False Positive A false positive is an error that reports an abnormality but no abnormality is present or the reader overemphasized the significance of a finding; eg, an atrial septal defect is diagnosed when no atrial septal defect is present.
Discrepant Diagnosis The actual diagnosis is different from the diagnosis made; eg, a diagnosis of double-inlet left ventricle is made when the actual diagnosis is tricuspid atresia. Severity Categorization Minor The minor severity category includes diagnostic errors or discrepancies that do not change patient management or affect clinical course with little or no potential for adverse event, eg, a missed left superior vena cava to an intact coronary sinus in a patient with an otherwise structurally normal heart.
Major This diagnostic error discrepancy has an impact on management that results in an adverse event, including performance of an unnecessary invasive procedure or long-lasting or permanent adverse event, eg, false-positive diagnosis of an atrial septal defect leading to an unnecessary surgery to close a defect that was not present. Catastrophic In this category, the diagnostic error or discrepancy contributed to patient death. Categorization of Preventability Not Preventable Diagnostic error is not preventable if the images, imaging modality, or imaging conditions do not permit diagnosis, eg, failure to image a ligamentum arteriosum contributing to a vascular ring.
Diagnostic Error Cause Categorization Table 1 catalogs factors contributing to diagnostic errors. Table 1 Contributors to Diagnostic Error Open in a separate window. Administrative or Data Entry Errors These errors typically precede the actual examination, eg, entering an examination report under an incorrect patient name.
Procedural or Conditional Factors Procedural or conditional factors relate to the performance of the study or the conditions under which the examination is performed, eg, failure to adequately interrogate the entire ventricular septum by color Doppler in a cooperative patient, resulting in a missed apical ventricular septal defect. Communication or Information Errors Errors in information transfer to those performing and interpreting the examination or from those interpreting the study to the referring clinician. Cognitive Errors Cognitive errors occur during the analysis of the imaging and clinical data.
Technical Factors These factors involve equipment malfunction or inherent limitations of echocardiography. Statistical Analysis The primary goal of the analysis was to identify factors associated with diagnostic errors related to postnatal echocardiography, including transthoracic, transesophageal, and intraoperative epicardial studies. Results Between December and August , 87 postnatal echocardiographic diagnostic error cases were identified. Contributors to Diagnostic Errors Factors contributing to diagnostic error are listed in Table 2.
Anatomy Involved With Diagnostic Error Table 3 illustrates the anatomy involved with diagnostic errors.
Diagnostic Error Discovery The median time to discovery of diagnostic errors was 5 days range, 0 days to Comparison of Preventable and Possibly Preventable Cases and Controls Results of univariate analysis, focusing on preventable and possibly preventable cases, are summarized in Table 4. Risk Factors for Preventable or Possibly Preventable Errors Multivariate analysis identified the following variables as risk factors for preventable or possibly preventable diagnostic errors Table 5: Discussion To the best of our knowledge, this is the first report within pediatric cardiology that not only examined the presence of a diagnostic error but also categorized severity, preventability, and causes of diagnostic errors.
Risk Factors for Preventable and Possibly Preventable Diagnostic Errors We identified both patient-related and situational risk factors for a diagnostic error. Study Limitations Selection bias and incomplete case ascertainment are notable limitations of this study. Conclusions A diagnostic error taxonomy and knowledge of risk factors can assist in the identification of targets for quality improvement initiatives that aim to reduce diagnostic errors in pediatric echocardiography.
Basics of Functional Echocardiography in Children and Neonates
Noninherited risk factors and congenital cardiovascular defects: Patient safety efforts should focus on medical errors. Complications and risk factors for mortality during congenital heart surgery admissions. Application of a complication screening method to congenital heart surgery admissions: Is routine preoperative cardiac catheterization necessary before repair of secundum and sinus venosus atrial septal defects? J Am Coll Cardiol.
Accuracy of two-dimensional echocardiography in the diagnosis of congenital heart disease.
Surgery without catheterization for congenital heart defects: Diagnosis of coronary artery anatomy by two-dimensional echocardiography in patients with transposition of the great arteries. Five years after To Err Is Human: Diagnostic error in internal medicine. Straddling mitral valve with hypoplastic right ventricle, crisscross atrioventricular relations, double outlet right ventricle and dextrocardia: Missed and delayed diagnoses in the ambulatory setting. Accuracy of echocardiography in low birth weight infants with congenital heart disease. Prenatal diagnosis of conotruncal malformations: Diagnostic accuracy of pediatric echocardiograms performed in adult laboratories.
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