Pediatric Emergency Department Provider Experience Using the Revised Safer Dx for Self-Directed Feedback on Diagnostic Performance

INTRODUCTION: Well-calibrated diagnostic performance requires feedback on decisions. Emergency department and urgent care (ED/UC) clinicians infrequently receive diagnostic performance feedback. We explored clinician experience with self-directed diagnostic performance review compared with diagnostic safety expert review. METHODS: Single-center, cohort study of pediatric ED/UC clinician self-directed case review involving possible diagnostic errors (DxEs). Participants reviewed their care of patients admitted within 10 days of an index ED/UC visit at risk of DxEs. The Revised Safer Dx provided structure for DxE identification and was compared with expert review by two diagnostic safety experts using Cohen kappa. Participants also reported their experience using the Revised Safer Dx. RESULTS: During the 1-year study period, 187 patients at risk of DxEs received index visit care from 260 ED/UC eligible clinicians. Seventy-one clinicians submitted reviews for 97 patient-clinician encounters (37.4% response rate). Agreement on the presence of DxEs ranged from 84.8% to 87.5%; Cohen kappa for expert 1 = 0.51 (95% confidence interval = 0.25-0.76); expert 2 = 0.54 (95% confidence interval = 0.17-0.92) indicating moderate agreement. More than 60% of participants agreed that the Revised Safer Dx provided a useful framework for reviewing diagnostic performance regardless of the presence of a DxE. Participants self-identifying a DxE were significantly more likely to have altered their diagnostic approach than those who did not (75.0% vs 5.7%; P < .001). DISCUSSION: ED/UC clinicians performing self-directed structured review for DxEs demonstrated moderate agreement with diagnostic safety experts indicating this method may aid diagnostic reasoning calibration. Promoting self-directed reviews may improve feedback delivery among ED/UC clinicians.