As the field of diagnostic safety research has evolved rapidly over the past decade, several attempts have been made to identify foundational research priorities both broadly and more specifically within pediatrics. The 2015 NAM report Improving Diagnosis in Healthcare highlighted the critical deficiencies in diagnostic error research compared with other patient safety events. The report identified four broad priority research topics related to diagnostic error60:
- Patient and family engagement in the diagnostic process.120
- Healthcare professional education and training.121
- Health information technology.122
- Identification, analysis, and reduction in diagnostic errors.
The priorities laid out within the NAM report have been echoed in more recent attempts to delineate priority research topics and questions. While the recommendations within the NAM report apply to pediatrics, the report does not call out any research priorities specific to pediatrics. This lack of attention to pediatrics is true of much of the available literature focused on diagnostic safety research priorities.
This section highlights high-quality papers that also apply to pediatrics, even if not providing pediatric-specific recommendations. Notably, a systematic review of MDOs in pediatrics highlighted the continued need to build foundational knowledge around the epidemiology of diagnostic safety events in children and to identify patient scenarios and populations at high risk for an MDO.123
Recently, a project bringing together various stakeholders in the diagnostic process attempted to delineate clear diagnostic safety research priorities in the form of specific, focused research questions. A systematic approach to gathering and ranking research questions submitted by a broad range of researchers, including experts across several disciplines and in 10 different countries, identified high-priority research questions to advance diagnostic safety research.124
A panel of subject matter experts reviewed and ranked 177 research questions on five criteria (usefulness, answerability, effectiveness, potential for translation, and maximal potential effect on diagnostic safety). This process resulted in 20 priority questions for advancing diagnostic safety research. As these priority topics were not specific to pediatrics, several require thoughtful design when considering children in diagnostic safety research (Table 1).
Table 1. Examples of pediatric considerations when setting research priorities in diagnostic safety
| Priority Research Question | Possible Pediatric Considerations |
|---|---|
| How can we best bring expert knowledge about diagnostic test selection and result interpretation to ordering providers at the point of care? | Reference ranges for tests often vary by age. Less familiarity with pediatric values among emergency physicians, general surgeons, and anesthesiologists may require unique methods to support proper interpretation. |
| How do we develop and evaluate performance of diagnostic trigger tools that can be used to identify or prevent diagnostic errors across the care continuum? | Trigger methodologies based on symptom-disease pairs may be harder to adapt to relatively healthy or nonverbal pediatric populations.125 For example, fever is a high-volume childhood complaint, but sepsis is a comparatively rare event. While meningitis is an important target for diagnostic safety research, the infants most at risk cannot report a headache. |
| What types of EHR design and functionality can effectively and efficiently summarize important historical patient context and new clinical findings to facilitate making an otherwise unrecognized diagnosis? | Parents are the first stewards of their children’s EHR information when those children may be incapable of managing its accuracy independently. As children become developmentally capable of assuming more of their own health care responsibilities, EHRs will need to address this transition as well as new diagnoses that present in adulthood related to congenital and childhood-acquired conditions. |
| Can we improve diagnostic safety by facilitating shared decision making in the diagnostic process, i.e., by discussing the risks and benefits of watchful waiting vs. additional diagnostic testing and treatment options? | Parents may be less willing to accept diagnostic uncertainty or delays for their children’s conditions compared with their own.39 Partnership with parents in preventing diagnostic error will likely require particular focus on addressing overdiagnosis and avoiding unnecessary testing. |
Note: Priority research questions were adapted from Zwaan, El-Kareh R, Meyer AND, Hooftman J, Singh H. Advancing diagnostic safety research: results of a systematic research priority setting exercise. J Gen Intern Med 2021;36:2943-2951. https://doi.org/10.1007/s11606-020-06428-3.
Within pediatrics, a growing number of stakeholders such as clinicians and healthcare leaders recognize that diagnostic safety is a priority topic in patient safety research.5 A narrative review of MDOs in pediatrics highlighted persistent gaps in the epidemiology of MDOs across pediatric disciplines compared with the literature on diagnostic safety in adult populations.10 This review also proposed several key research questions that focus on better establishing the causes and epidemiology of MDOs and developing evidence-based interventions to improve diagnostic safety specific to pediatrics. The importance of equity in the diagnostic process and in diagnostic safety research has also been highlighted by the Society to Improve Diagnosis in Medicine (SIDM).126
There is also an increasing focus on the concept of safety II or resilience engineering.127 Traditional patient safety approaches, or safety I, focus on creating standard processes and systems that limit the opportunity for things to go wrong. In contrast, safety II assumes that everyday performance variability provides the necessary adaptation to respond appropriately to inevitable variations in even the most well-designed systems.
Resilience at the individual, team, or systems level can be the reason things go right. For example, Ramnarayan and colleagues have demonstrated that less experienced clinicians will be alerted to important and “must-not-miss” diagnoses more often when using a web-based differential diagnosis support tool.128 Limited evidence suggests that such tools may even decrease the likelihood of pursuing unsafe diagnostic evaluations at the risk of missing important conditions.129
As diagnostic safety research advances, we should not only focus on learning from failures in the diagnostic process but also try to learn from cases where, despite its complexity, the diagnostic process or journey goes well and correct, timely diagnoses are achieved.
To date, diagnostic safety research funding has largely relied on federal agencies, such as AHRQ, and private entities, primarily the Gordon and Betty Moore Foundation. However, research and funding to improve diagnosis remain disproportionately focused on adults. In a brief query of the National Institutes of Health (NIH) RePORTER, the authors found that only 10 percent of AHRQ and NIH funding in diagnostic safety specifically focused on pediatric care. To overcome this disparity, future efforts should include:
- Heightened advocacy efforts focused on improving the diagnostic process for pediatric patients.
- Training and mentoring pediatric diagnostic safety researchers.
- Dedicated funding allocated to pediatric-specific initiatives.
