Diagnostic errors are common in acute pediatric respiratory disease: a prospective, single-blinded multicenter diagnostic accuracy study in Australian Emergency Departments

Abstract

ABSTRACTBackgroundDiagnostic errors are a global health priority and a common cause of preventable harm. There is limited data available for the prevalence of misdiagnosis in pediatric acute-care settings. Respiratory illnesses, which are particularly challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments.ObjectiveTo determine the diagnostic error rate of acute childhood respiratory diseases in emergency departments.MethodsProspective, multicenter, single-blinded, diagnostic accuracy study in two well-resourced pediatric emergency departments in a large Australian city. Between September 2016 and August 2018, a convenience sample of children aged 29 days to 12 years who presented with respiratory symptoms was enrolled. The emergency department discharge diagnoses were reported by clinicians based upon standard clinical diagnostic definitions. These diagnoses were compared against consensus diagnoses given by an expert panel of pediatric specialists using standardized disease definitions after they reviewed all medical records.ResultsFor 620 participants, the positive and negative percent agreement (%, [95% CI]) of the emergency department compared with the expert panel diagnoses were generally poor: isolated upper respiratory tract disease (61.4 [51.2, 70.9], 90.9 [88.1, 93.3]), croup (75.6 [64.9, 84.4], 97.9 [96.2, 98.9]), lower respiratory tract disease (86.4 [83.1, 89.6], 92.9 [87.7, 96.4]), bronchiolitis (66.9 [58.6, 74.5], 94.3 [80.8, 99.3]), asthma/reactive airway disease (91.0 [85.8, 94.8], 93.0 [90.1, 95.3]), clinical pneumonia (62·9 [49·7, 74·8], 95·0 [92·8, 96·7]), focal (consolidative) pneumonia (54·8 [38·7, 70·2], 86.2 [79.3, 91.5]). Only 59% of chest x-rays with consolidation were correctly identified. Between 6.9% and 14.5% of children were inappropriately prescribed based on their eventual diagnosis.ConclusionIn well-resourced emergency departments, we have identified a previously unrecognized high diagnostic error rate for acute childhood respiratory disorders, particularly in pneumonia and bronchiolitis. These errors lead to the potential of avoidable harm and the administration of inappropriate treatment.