A synthesized differential diagnosis is associated with fewer diagnostic errors compared to an inventorial list.

Abstract

Objectives: Emergency department (ED) encounters carry high risk of diagnostic error. Understanding how providers process information and reach diagnostic conclusions may identify interventions to reduce diagnostic errors. We aimed to determine if pediatric ED notes documenting a simple inventory of alternative diagnoses (inventorial differential diagnosis (DDx)) increased the odds of subsequent diagnostic error compared to encounters where the DDx was explicitly linked to specific data elements in the encounter (synthesized).

Methods: This is a cohort study of children 0-22 years who experienced unplanned admission within 10 days of an index pediatric ED or urgent care visit. Documented DDx (inventorial vs. synthesized) in the index visit notes served as the predictor variable. The primary outcome was presence of diagnostic error. Propensity scores were created using patient demographics and complexity and visit acuity. Propensity score matched patients were compared with multivariable conditional logistic regression to assess association between documented DDx and diagnostic error.

Results: Propensity scores matched 303 patient pairs of inventorial and synthesized DDx from 869 charts screened in for review. The adjusted odds ratio for diagnostic error at a subsequent unplanned admission was 1.79 (95 % CI 1.17-2.75) when an inventorial DDx was documented relative to synthesized. This finding includes adjustments for the number of diagnostic tests, obtaining a subspecialty consult and number of hospitalizations in the prior 6 months.

Conclusions: An inventorial DDx in pediatric emergency medical decision making is associated with significantly higher odds of subsequent diagnostic error, offering an actionable, simple opportunity for all providers to improve patient care.