Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

Nikhil Raghuram; Khalid Alodan; Ute Bartels; Sarah Alexander; Jason D Pole; Paul Gibson; Donna L Johnston; Carol Portwine; Mariana Silva; Lillian Sung

Study

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

September 22, 2021

Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478(6):1179-1185.

View more articles from the same authors.

Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.

PubMed citation

Available at

Related Resources From the Same Author(s)

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.

July 28, 2021

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology: a meta-analysis and review.

December 1, 2005

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

Medicines reconciliation in the emergency department: important prescribing discrepancies between the shared medication record and patients' actual use of medication.

March 16, 2022

Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.

October 14, 2020

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations.

March 17, 2021

Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.

December 8, 2021

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

December 7, 2022

Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals.

October 14, 2020

Redeployment of health care workers in the COVID-19 pandemic: a qualitative study of health system leaders' strategies.

May 19, 2021

Preventable morbidity and mortality among non-trauma emergency surgery patients: the role of personal performance and system flaws in adverse events.

May 12, 2021

Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice

January 22, 2020

Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study.

September 15, 2021

Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.

August 8, 2012

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

May 4, 2022

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.

May 12, 2021

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

April 20, 2022

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.

March 27, 2005

Association of provider specialty with abortion-related morbidity and adverse events among patients having procedural and medication abortions.

August 10, 2022

State medical board regulation of compounding in physician offices.

June 9, 2021

Clinical decision support improves the appropriateness of laboratory test ordering in primary care without increasing diagnostic error: the ELMO cluster randomized trial.

December 2, 2020

Individualized medication review in older people with multimorbidity: a comparative analysis between patients living at home and in a nursing home.

May 25, 2022

A pause in pediatrics: implementation of a pediatric diagnostic time-out.

September 14, 2022

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

December 16, 2020

Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning.

May 5, 2021

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

Accuracy of emergency department clinical findings for diagnosis of coronavirus disease 2019.

July 29, 2020

Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest.

July 8, 2020

More than words: patients' views on apology and disclosure when things go wrong in cancer care.

August 24, 2011

Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students.

September 9, 2020

A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain.

July 14, 2021

Analysis of variation between diagnosis at admission vs discharge and clinical outcomes among adults with possible bacteremia.

July 13, 2022

Testimonial injustice: linguistic bias in the medical records of black patients and women.

June 6, 2021

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study.

August 11, 2021

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.

April 12, 2023

I-PASS illness diversity identifies patients at risk for overnight clinical deterioration.

December 2, 2020

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.

December 7, 2022

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

October 13, 2021

Advancing diagnostic safety research: results of a systematic research priority setting exercise.

February 24, 2021

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

December 22, 2021

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review.

April 20, 2022

Evaluation of a second victim peer support program on perceptions of second victim experiences and supportive resources in pediatric clinical specialties using the second victim experience and support tool (SVEST).

November 3, 2021

Ethical challenges in child abuse: what is the harm of a misdiagnosis?

June 9, 2021

Creating a learning health system for improving diagnostic safety: pragmatic insights from US health care organizations.

June 22, 2022

Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care.

November 11, 2020

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.

May 18, 2022

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

Reducing pediatric emergency department prescription errors.

June 22, 2022

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

Clinical features and preventability of delayed diagnosis of pediatric appendicitis.

September 29, 2021

Post-discharge adverse events among African American and Caucasian patients of an urban community hospital.

July 15, 2020

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.

June 8, 2022

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

December 16, 2020

Association between language use and ICU transfer and serious adverse events in hospitalized pediatric patients who experience rapid response activation.

August 17, 2022

Patients' experiences and perspectives of patient-reported outcome measures in clinical care: a systematic review and qualitative meta-synthesis.

May 11, 2022

More than an apple a day: factors associated with avoidance of doctor visits among transgender, gender nonconforming, and nonbinary people in the USA.

September 23, 2020

Recognition of adverse drug events in older hospitalized medical patients.

July 11, 2012

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

August 10, 2022

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

Analyzing diagnostic errors in the acute setting: a process-driven approach.

October 20, 2021

Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia.

August 24, 2022

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

Design of a safety dashboard for patients.

December 18, 2019

Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors.

September 8, 2021

The relationship between response time and diagnostic accuracy.

August 15, 2012

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

November 11, 2020

Effectiveness of using simulation in the development of clinical reasoning in undergraduate nursing students: a systematic review.

December 1, 2021

Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department.

October 14, 2020

Prolonged diagnostic intervals as marker of missed diagnostic opportunities in bladder and kidney cancer patients with alarm features: a longitudinal linked data study.

February 17, 2021

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory.

December 22, 2021

Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study.

October 6, 2021

National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide.

June 1, 2022

A randomized clinical trial to compare the use of safety net enclosures with standard restraints in agitated hospitalized patients.

January 9, 2008

Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey.

April 12, 2023

Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement.

July 28, 2021

Automated identification of diagnostic labelling errors in medicine.

June 8, 2022

Strategies to reduce errors associated with 2-component vaccines.

December 2, 2020

Bringing the clinical laboratory into the strategy to advance diagnostic excellence.

September 22, 2021

A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study.

February 6, 2019

Clinical reasoning in dire times- analysis of cognitive biases in clinical cases during the COVID-19 pandemic.

February 23, 2022

Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.

April 11, 2012

Associations between safety outcomes and communication practices among pediatric nurses in the United States.

January 19, 2022

Safety in pediatric hospice and palliative care: a qualitative study.

September 23, 2020

Medication errors in overweight and obese pediatric patients: a systematic review.

February 9, 2022

Deprescribing for community-dwelling older adults: a systematic review and meta-analysis.

September 16, 2020

Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey.

September 2, 2020

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.

October 5, 2016

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

December 1, 2021

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

June 15, 2022

Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnostic accuracy.

August 11, 2021

Standardization of compounded oral liquids for pediatric patients in Michigan.

August 31, 2016

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

October 5, 2022

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

Effect of different interventions to help primary care clinicians avoid unsafe opioid prescribing in opioid-naive patients with acute noncancer pain: a cluster randomized clinical trial.

September 7, 2022

Medication errors reported in a pediatric intensive care unit for oncologic patients.

September 14, 2011

Related Resources

Current State of Diagnostic Safety: Implications for Research, Practice, and Policy.

February 7, 2024

Low rate of completion of recommended tests and referrals in an academic primary care practice with resident trainees.

January 31, 2024

These patients had to lobby for correct diabetes diagnoses. Was their race a reason?

January 17, 2024

WebM&M Cases

Delay in Malignancy Diagnosis Reflects Systemic Failures

October 31, 2023

Hospital Harm Project.

October 31, 2023

The delivery of safe and effective test result communication, management and follow-up.

September 27, 2023

Experimental evidence for structured information-sharing networks reducing medical errors.

August 9, 2023

Burden of serious harms from diagnostic error in the USA.

July 28, 2023

What causes delays in diagnosing blood cancers? A rapid review of the evidence.

July 5, 2023

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

July 5, 2023

Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable.

May 17, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Cancer drug shortages are creating dire circumstances for some patients.

April 26, 2023

STAMP: a 5-year project to reduce paediatric prescribing errors.

April 19, 2023

WebM&M Cases

Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.

March 29, 2023

Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study.

February 8, 2023

Using community detection techniques to identify themes in COVID-19-related patient safety event reports.

December 7, 2022

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

November 30, 2022

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

WebM&M Cases

Delayed Diagnosis of Mesenteric Ischemia

August 31, 2022

How safe are paediatric emergency departments? A national prospective cohort study.

August 3, 2022

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

May 4, 2022

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.

April 13, 2022

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

March 23, 2022

Radiologist errors by modality, anatomic region, and pathology for 1.6 million exams: what we have learned.

March 2, 2022

Technology-based closed-loop tracking for improving communication and follow-up of pathology results.

February 2, 2022

Epidemiology of healthcare harm in New Zealand general practice: a retrospective records review study.

July 28, 2021

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop.

June 2, 2021

See More About The Topic

Hospitals

Ambulatory Clinic or Office

Health Care Providers

Quality and Safety Professionals

Pediatric Medical Oncology

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site