Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE. Issue 3 (May 2020)

• Record Type: Journal Article
• Authors: Dadlez, Nina M.; Adelman, Jason; Bundy, David G.; Singh, Hardeep; Applebaum, Jo R.; Rinke, Michael L.
• Is Part Of: Pediatric quality & safety. Volume 5:Issue 3(2020)
• Publication Date: 2020-05
• Subjects: Pediatric nursing -- Periodicals; Pediatrics -- Periodicals; Patients -- Safety measures -- Periodicals; Children -- Hospital care -- Periodicals; 618.92
• DOI: 10.1097/pq9.0000000000000299
• Languages: English
• ISSNs: 2472-0054

Abstract

Abstract : Background: Pediatric ambulatory diagnostic errors (DEs) occur frequently. We used root cause analyses (RCAs) to identify their failure points and contributing factors. Methods: Thirty-one practices were enrolled in a national QI collaborative to reduce 3 DEs occurring at different stages of the diagnostic process: missed adolescent depression, missed elevated blood pressure (BP), and missed actionable laboratory values. Practices were encouraged to perform monthly "mini-RCAs" to identify failure points and prioritize interventions. Information related to process steps involved, specific contributing factors, and recommended interventions were reported monthly. Data were analyzed using descriptive statistics and Pareto charts. Results: Twenty-eight (90%) practices submitted 184 mini-RCAs. The median number of mini-RCAs submitted was 6 (interquartile range, 2–9). For missed adolescent depression, the process step most commonly identified was the failure to screen (68%). For missed elevated BP, it was the failure to recognize (36%) and act on (28%) abnormal BP. For missed actionable laboratories, failure to notify families (23%) and document actions on (19%) abnormal results were the process steps most commonly identified The term failure modes is related to a specific form of analysis that we didn't perform so I am hesitant to use this language. Top contributing factors to missed adolescent depression included patient volume (16%) and inadequate staffing (13%). Top contributing factors to missed elevated BP included patient volume (12%), clinic milieu (9%), and electronic health records (EHRs) (8%). Top contributing factors to missed actionable laboratories included written communication (13%), EHR (9%), and provider knowledge (8%). Recommended interventions were similar across errors. Conclusions: EHR-based interventions, standardization of processes, and cross-training may help decrease DEs in the pediatric ambulatory setting. Mini-RCAs are useful tools to identify their contributing factors and interventions. Abstract : Supplemental Digital Content is available in the text.