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G330(P) Introduction of consultant delivered care is associated with a reduced incidence of diagnostic errors in acute medical admissins in a district general hospital
  1. P Patel1,
  2. C Warrick2,
  3. H Hyer1,
  4. D Inwald3
  1. 1Paediatrics, Northwick Park Hospital, Harrow, UK
  2. 2Neonatalogy, Queen Charlotte’s and Chelsea Hospital, London, UK
  3. 3Paediatric Intensive Care Unit, St Mary’s, Imperial College London, London, UK

Abstract

Aim Diagnostic errors (DEs) are common yet under-recognised factors in malpractice claims and often associated with cognitive error.1,2 Consultant delivered care (CDC) is being implemented UK wide to improve patient safety yet its impact on DEs is unstudied. We previously conducted a study at a district general emergency department (ED) where a 5% DE incidence amongst acute paediatric medical admissions was noted.3 The study site then introduced a CDC model. This study aimed to determine the impact of CDC on DE incidence.

Methodology An observational before and after study utilising our previous data3 as a retrospective control. The methodology of our previous study was repeated for intervention CDC hours (10:00–22:00 Weekdays and 14:00–22:00 weekends) and non-CDC hours (parallel control). Paediatric medical admissions were screened for DEs by identifying changes in diagnosis from admission to discharge and confirmed through case-notes review. DEs were further studied by two reviewers to categorise causative factors using a standardised taxonomy.4 Structured interviews of clinicians were performed and analysed using a thematic framework.5

Results DE incidence fell from 5% pre-CDC to 2.0% overall afterwards (RR 2.57 95 CI 1.28–5.15). The DE incidence in the CDC cohort was 2.3% (RR 2.17 95 CI 1–4.75 compared to the retrospective control). DEs were fewer in non-CDC hours compared to the CDC hours at 1.5% but this was not statistically significant. DE cases during CDC hours compared to those in the Warrick cohort were associated with less cognitive errors (RR 0.79, 95 CI 0.65–0.96) but more system errors (RR 1.9 95 CI 1.1–3.3).

Conclusion A reduction in DEs was noted following implementation of CDC. There are a number of possible explanations. This could be due to direct consultant involvement, improved trainee supervision or awareness of cognitive bias. The latter could potentially have an impact, through trainees, during non-CDC hours. The significantly lower ED attendances post CDC may mean less system related pressures in which DEs are less likely. Similarly increased paediatric nursing may have improved efficiency and enhanced support for trainee doctors. This study is unable to clarify the impact of these factors and further work into the impact of CDC on DEs is needed.

References

  1. Sevdalis N, Jacklin R, Arora S, Vincent CA. Thomson RG. Diagnostic Error in a National Incident Reporting System in the UK. Journal of Evaluation in Clinical Practice 2010; 16(6):1276–1281

  2. Graber ML. The incidence of diagnostic error in medicine. BMJ Quality & safety 2013; 22(Suppl 2):ii21–ii27

  3. Warrick C, Patel P, Hyer W, Neale G, Sevdalis N, Inwald D. Diagnostic error in children presenting with acute medical illness to a community hospital. International journal for quality in health care. Journal of the International Society for Quality in Health Care/ISQua 2014; 26(5):538–546

  4. Pope C, van Royen P, Baker R. Qualitative methods in research on healthcare quality. Quality & safety in health care 2002; 11(2):148–152

  5. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Archives of Internal Medicine 2005; 165(13):1493–1499

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