National Healthcare Quality and Disparities Report
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 13 of 13 Research Studies DisplayedCifra CL, Custer JW, Smith CM
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
This study’s objective was to determine the prevalence and characteristics of diagnostic errors and identify factors associated with error in patients admitted to the PICU. This multicenter cohort study used structured medical record review by trained clinicians using the Revised Safer Dx instrument to identify diagnostic error (defined as missed opportunities in diagnosis). The cohort included 882 randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. Of these admissions, 13 (1.5%) had a diagnostic error up to 7 days after PICU admission, with infections (46%) and respiratory conditions (23%) being the most missed diagnoses. One diagnostic error caused a prolonged hospital stay. Common missed diagnostic opportunities included failure to consider the diagnosis despite a suggestive history and failure to broaden diagnostic testing, both at 69%. Unadjusted analysis identified more diagnostic errors in patients with atypical presentations (23.1% vs 3.6%), neurologic chief complaints (46.2% vs 18.8%), admitting intensivists greater than or equal to 45 years old (92.3% vs 65.1%), admitting intensivists with more service weeks/year (mean 12.8 vs 10.9 weeks), and diagnostic uncertainty on admission (77% vs 25.1%). Generalized linear mixed models determined that atypical presentation (odds ratio [OR] 4.58) and diagnostic uncertainty on admission (OR 9.67) were significantly associated with diagnostic error.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Smith CM .
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Crit Care Med 2023 Nov; 51(11):1492-501. doi: 10.1097/ccm.0000000000005942..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Critical Care, Intensive Care Unit (ICU), Medical Errors, Patient Safety
Woods-Hill CZ, Koontz DW, Colantuoni EA
Sustainability of the Bright STAR diagnostic stewardship program to reduce blood culture rates among critically ill children.
From 2017 to2020, 14 pediatric intensive care units (PICUs) participated in the Bright STAR (Testing Stewardship for Antibiotic Reduction) QI collaborative to reduce unnecessary blood cultures for PICU patients. The collaborative project found that 4 sites demonstrated a 33% decrease in blood culture rates and a 13% decrease in broad spectrum antibiotic use. The purpose of this current study was to assess whether sites sustained reduced blood culture rates after completion of the formal project. The study found that all sites had lower blood culture rates during the sustainability period when compared with the pre-implementation period. The blood culture rate increased 8% during the sustainability period compared with the postimplementation period but was 27% lower than during the pre-implementation period.
AHRQ-funded; HS025642.
Citation: Woods-Hill CZ, Koontz DW, Colantuoni EA .
Sustainability of the Bright STAR diagnostic stewardship program to reduce blood culture rates among critically ill children.
JAMA Pediatr 2023 Nov; 177(11):1234-37. doi: 10.1001/jamapediatrics.2023.3229..
Keywords: Children/Adolescents, Critical Care, Quality Improvement, Diagnostic Safety and Quality, Quality of Care
Shafer GJ, Singh H, Thomas EJ
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
The objective of this study was to determine the frequency and etiology of diagnostic errors during the first 7 days of admission for inborn neonatal intensive care unit (NICU) patients. The "Safer Dx NICU Instrument" was used to review electronic health records. The reviewers discovered that the frequency of diagnostic error in inborn NICU patients during the first 7 days of admission was 6.2%.
AHRQ-funded; HS027363.
Citation: Shafer GJ, Singh H, Thomas EJ .
Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.
J Perinatol 2022 Oct;42(10):1312-18. doi: 10.1038/s41372-022-01359-9..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Critical Care, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Ramesh S, Ayres B, Eyck PT
Impact of subspecialty consultations on diagnosis in the pediatric intensive care unit.
This retrospective study used chart reviews of critically ill children in the pediatric intensive care unit (PICU) to determine the impact of subspecialty consultations on diagnosis. The majority of patients (87 of 101) were provided subspecialty consultations at the request of the PICU clinician. The consultations were equally for diagnosis (65%) and treatment (66%). There was a change in diagnosis for 21% of patients with consultants from PICU admission to discharge, with 61% attributed to subspecialty input. Forty-five percent of patients with consultations had additional imaging and/or laboratory testing and 55% had a medication change and/or a procedure performed immediately after consultation.
AHRQ-funded; HS026965.
Citation: Ramesh S, Ayres B, Eyck PT .
Impact of subspecialty consultations on diagnosis in the pediatric intensive care unit.
Diagnosis 2022 Aug;9(3):379-84. doi: 10.1515/dx-2021-0137..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Diagnostic Safety and Quality
Woods-Hill CZ, Colantuoni EA, Koontz DW
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.
The purpose of this AHRQ-funded prospective study was to assess the relationship between a 14-site PICU blood culture collaborative, the Bright STAR (Testing Stewardship for Antibiotic Reduction) collaborative, and culture rates, antibiotic use, and patient outcomes. The researchers collected data from each participating PICU across the United States and from the Children’s Hospital Association Pediatric Health Information System. The main outcome was blood culture rates, with secondary outcomes including: broad-spectrum antibiotic use and PICU rates of central line-associated bloodstream infection (CLABSI), Clostridioides difficile infection, readmission, length of stay, sepsis, severe sepsis/septic shock, and mortality. The study found that the blood culture rate preimplementation across the 14 PICUs was 149.4 per 1000 patient days per month, and the rate postimplementation was 100.5 for a 33% relative reduction postimplementation. For those same periods, the rate of antibiotic use decreased from 506 days per 1000 patient-days per month preimplementation to 440 days per 1000 patient-days per month postimplementation, which reflects a 13% relative reduction. Rates of CLABSI decreased from 1.8 to 1.1 per 1000 central venous line days per month, a 36% relative reduction. The variables of length of stay, readmission, sepsis, severe sepsis/septic shock, and mortality were similar before and after implementation. The researchers concluded that collaborative interventions can reduce blood culture and antibiotic use in the PICU.
AHRQ-funded; HS025642.
Citation: Woods-Hill CZ, Colantuoni EA, Koontz DW .
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.
JAMA Pediatr 2022 Jul;176(7):690-98. doi: 10.1001/jamapediatrics.2022.1024..
Keywords: Children/Adolescents, Sepsis, Critical Care, Antibiotics, Medication, Diagnostic Safety and Quality, Antimicrobial Stewardship
Vivtcharenko VY, Ramesh S, Dukes K
Diagnosis documentation of critically ill children at admission to a PICU.
This study’s objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission. PICU admission notes for 96 unique patients were reviewed. Findings showed that most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Recommendations included future work to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
AHRQ-funded; HS026965; HS022087.
Citation: Vivtcharenko VY, Ramesh S, Dukes K .
Diagnosis documentation of critically ill children at admission to a PICU.
Pediatr Crit Care Med 2022 Feb;23(2):99-108. doi: 10.1097/pcc.0000000000002812..
Keywords: Children/Adolescents, Critical Care, Intensive Care Unit (ICU), Diagnostic Safety and Quality
Cifra CL, Custer JW, Singh H
Diagnostic errors in pediatric critical care: a systematic review.
This study is a systematic review on the prevalence, impact, and contributing factors related to diagnostic errors in the PICU. A database search was done for literature up through December 2019. Using specific criteria, 396 abstracts were screened, and 17 studies were included. Fifteen of 17 studies had an observational research design. Autopsy studies showed a 10-23% rate of missed major diagnosis with 5-16% of the errors having a potential adverse impact on survival and would have changed care management. Retrospective record review studies reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions. About a quarter of those patients were discussed at PICU morbidity and mortality conferences. Most misdiagnosed conditions were cardiovascular, infectious, congenital, or neurologic. System, cognitive, and both system and cognitive factors were associated with diagnostic error but there is limited information on the impact of misdiagnosis.
AHRQ-funded; HS026965.
Citation: Cifra CL, Custer JW, Singh H .
Diagnostic errors in pediatric critical care: a systematic review.
Pediatr Crit Care Med 2021 Aug;22(8):701-12. doi: 10.1097/pcc.0000000000002735..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Intensive Care Unit (ICU), Critical Care
Cifra Cifra, CL Dukes, KC Ayres, et al.
Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: a pilot ethnography.
This pilot study’s goal was to determine the feasibility of using focused ethnography to understand the relationship between referral communication and the diagnostic process for critically ill children. Findings showed that focused ethnography in the pediatric intensive care unit is feasible to investigate relationships between clinician referral communication and the diagnostic process for critically ill children.
AHRQ-funded; HS026965.
Citation: Cifra Cifra, CL Dukes, KC Ayres, et al..
Referral communication for pediatric intensive care unit admission and the diagnosis of critically ill children: a pilot ethnography.
J Crit Care 2021 Jun;63:246-49. doi: 10.1016/j.jcrc.2020.09.011..
Keywords: Children/Adolescents, Communication, Critical Care, Intensive Care Unit (ICU), Diagnostic Safety and Quality
Cifra CL, Ten Eyck P, Dawson JD
Factors associated with diagnostic error on admission to a PICU: a pilot study.
This pilot retrospective cohort study examined errors in pediatric ICUs (PICUs) for children during the first 12 hours after PICU admission. A structured tool (Safer Dx) was used to identify diagnostic error in an academic tertiary institution. Out of 50 patients, 4 (8%) had diagnostic errors. The errors were in diagnoses of chronic ear infection, intracranial pressure (two cases), and Bartonella encephalitis. This pilot study will be expanded into a larger and more definitive multicenter study.
AHRQ-funded; HS022087.
Citation: Cifra CL, Ten Eyck P, Dawson JD .
Factors associated with diagnostic error on admission to a PICU: a pilot study.
Pediatr Crit Care Med 2020 May;21(5):e311-e15. doi: 10.1097/pcc.0000000000002257..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Critical Care, Intensive Care Unit (ICU), Hospitals
Klompas M, Osborn TM, Rhee C
Who owns sepsis?
In this Ideas and Opinions article, the authors discuss applying to sepsis guidelines that are already in place for other conditions. They indicate that other time-critical diagnoses have evolved triaging systems to inform the urgency and intensity of therapy, and that sepsis can evolve similarly, where potentially infected patients with worrisome signs or comorbidities, such as hypotension, altered mental status, or immunosuppression, are managed with one level of urgency and intensity and less severely ill patients are managed with another.
AHRQ-funded; HS025008.
Citation: Klompas M, Osborn TM, Rhee C .
Who owns sepsis?
Ann Intern Med 2020 Feb 4;172(3):210-11. doi: 10.7326/m19-2966..
Keywords: Sepsis, Guidelines, Diagnostic Safety and Quality, Critical Care
Bergl PA, Nanchal RS, Singh H
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Despite progress in ICU safety, diagnostic errors remain largely unexplored and under-studied in critical care. Compared to other safety problems, diagnostic errors are more difficult to identify and, due to the intricacies of the diagnostic process, are more difficult to unravel. This paper discusses diagnostic error in critically ill patients, defines the problem and explores next steps to advance ICU safety.
AHRQ-funded; HS022087.
Citation: Bergl PA, Nanchal RS, Singh H .
Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.
Ann Am Thorac Soc 2018 Aug;15(8):903-07. doi: 10.1513/AnnalsATS.201801-068PS..
Keywords: Adverse Events, Critical Care, Diagnostic Safety and Quality, Intensive Care Unit (ICU), Medical Errors, Patient Safety
Sjoding MW, Prescott HC, Wunsch H
Longitudinal changes in ICU admissions among elderly patients in the United States.
The researchers sought to describe the changing demographics, diagnoses, and outcomes of patients admitted to critical care units in the U.S. hospitals. They ound that patients with infectious diseases increased from 8.8 percent to 17.2 percent of admissions, and explicitly labeled sepsis moved from the 11th-ranked diagnosis in 1996 to the top-ranked primary discharge diagnosis in 2010.
AHRQ-funded; HS020672.
Citation: Sjoding MW, Prescott HC, Wunsch H .
Longitudinal changes in ICU admissions among elderly patients in the United States.
Crit Care Med 2016 Jul;44(7):1353-60. doi: 10.1097/ccm.0000000000001664.
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Keywords: Elderly, Intensive Care Unit (ICU), Hospitalization, Diagnostic Safety and Quality, Critical Care
Murray DJ, Freeman BD, Boulet JR
Decision making in trauma settings: simulation to improve diagnostic skills.
The objective of this study was to determine whether simulation could be used to provide teams the experiences in managing scenarios that require the use of heuristic as well as analytic diagnostic skills to effectively recognize and treat potentially life-threatening injuries. The results of this preliminary study indicates that teams led by more senior residents received higher scores when managing heuristic scenarios but were less effective when managing the scenarios that require a more analytic approach.
AHRQ-funded; HS018734; HS022265.
Citation: Murray DJ, Freeman BD, Boulet JR .
Decision making in trauma settings: simulation to improve diagnostic skills.
Simul Healthc 2015 Jun;10(3):139-45. doi: 10.1097/sih.0000000000000073..
Keywords: Shared Decision Making, Diagnostic Safety and Quality, Critical Care, Patient Safety, Medical Errors