CC BY-NC-ND 4.0 · AJP Rep 2018; 08(04): e379-e383
DOI: 10.1055/s-0038-1676619
Case Report
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Diagnostic Errors in the Neonatal Intensive Care Unit: A Case Series

Grant J. Shafer
1   Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
2   Department of Neonatology, Texas Children's Hospital, Houston, Texas
,
Gautham Suresh
1   Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
2   Department of Neonatology, Texas Children's Hospital, Houston, Texas
› Author Affiliations
Funding Source No funding was secured for this manuscript.
Further Information

Publication History

14 August 2018

03 November 2018

Publication Date:
26 December 2018 (online)

Abstract

Diagnostic errors remain understudied in neonatal intensive care units (NICUs). The few available studies are primarily autopsy-based, and do not evaluate diagnostic errors that did not result in the patient's death. This case series presents 10 examples of nonlethal diagnostic errors in the NICU—classified according to the component of the diagnostic process which led to the error. These cases demonstrate the presence of diagnostic error in the NICU and highlight the need for further research on this important topic.

Financial Disclosure

The authors have no financial relationships relevant to this article to disclose.


 
  • References

  • 1 Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine et al. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015
  • 2 Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf 2013; 22 (Suppl. 02) ii21-ii27
  • 3 Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf 2005; 31 (02) 106-113
  • 4 Custer JW, Winters BD, Goode V. , et al. Diagnostic errors in the pediatric and neonatal ICU: a systematic review. Pediatr Crit Care Med 2015; 16 (01) 29-36
  • 5 Widmann R, Caduff R, Giudici L. , et al. Value of postmortem studies in deceased neonatal and pediatric intensive care unit patients. Virchows Arch 2017; 470 (02) 217-223
  • 6 Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal?. Acad Med 2002; 77 (10) 981-992
  • 7 Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf 2015; 24 (02) 103-110