Preventable harm and child maltreatment diagnosis
The systematic review and meta-analysis by Panagioti et al. (1) on preventable patient harm raise important, general issues concerning how to promote resilient health care organization and to preserve public trust in health care. Preventable harm by diagnosis was defined as “Missed, wrong, delayed or inappropriate diagnostic incidents resulting from failure to capture documented signs, symptoms, and laboratory tests, not ordering and indicated diagnostic test or not undertaking adequate patient assessment.” (eTable 1). Among the 66 studies included in their review, diagnostic errors contributed to 16% of preventable harm. A Medline search for “diagnostic errors” had 38,362 hits. Although the diagnosis of child maltreatment was not part of this comprehensive review, diagnostic precision in detection of child maltreatment is of the utmost importance to avoid false positive as well as false negative diagnoses, as in both cases the consequences can be most severe.
We performed a Medline search for “diagnostic errors child maltreatment” and found 381 hits in the period 1975-2019. Of relevance were 147 contributions representing observational hospital studies, comments, letters, and case reports. These addressed correct diagnosis by discussing false negatives and false positives where medical conditions had been mistaken for abuse and how to improve the diagnostic procedure by medical technology such as imaging. However, there is no gold standard to diagnose child maltreatment, especially infant physical abuse; it is still an area of evolving knowledge.
Population register studies addressing infant maltreatment diagnosis might give clues how to improve patient safety, both when a correct diagnosis can be lifesaving, but also for parents seeking health care when maltreatment is not the case. We have demonstrated that subdural haemorrhage, skull fracture, retinal haemorrhage, fractures of rib and long bones are all strongly correlated with infant abuse diagnosis, and the use of this diagnosis shows a substantial increase over time with pronounced regional disparities (2), and an increase in babies removed from their parents to out-of-home care (3). On the other hand, on a population level, a minor proportion of those having a subdural haemorrhage had a diagnosis of infant abuse, most were associated to short falls, male sex, and also to prematurity, multiple births, and small-for gestational age (4). On a population level we have further shown that rib or long bone fractures during infancy are strongly associated with metabolic bone disease (5). However, specificity and sensitivity of medical markers for a correct maltreatment diagnosis cannot be addressed by population register studies.
The need to build an evidence based diagnostic work-up for infant maltreatment addressed by the systematic review of the Swedish agency for health technology assessment and assessment of social services concluded that “There is insufficient scientific evidence on which to assess the diagnostic accuracy of the triad in identifying traumatic shaking (very low quality evidence).”
We do agree with the conclusion of Panagioti et al., “Improving the assessment and reporting standards of preventability in future studies is critical for reducing patient harm in medical care settings”. Clinical studies on the diagnosis of infant abuse, derived from updated knowledge, are warranted and overdue.
Ulf Högberg, MD, PhD, Department of Women’s and Children’s Health, Uppsala University, Sweden
Waney Squier, FRCP, FRCPath, Formerly Department of Neuropathology, Oxford University John Radcliffe Hospital, United Kingdom
Ingemar Thiblin, MD, PhD, Forensic Medicine, Department of Surgical Sciences, Uppsala University, Sweden
Vineta Fellman MD, PhD, Department of Clinical Sciences, Lund, Pediatrics, Lund University, Lund, Sweden, Children’s Hospital, University of Helsinki and Folkhälsan Research Center, Helsinki, Finland
Göran Högberg, MD, PhD, Formerly Department of Women’s and Children’s Health, Child and Adolescent Psychiatric Unit, Karolinska Institutet, Stockholm, Sweden
Jacob Andersson, MD, Forensic Medicine, Department of Surgical Sciences, Uppsala University, Sweden
Knut Wester, MD, PhD, Department of Clinical Medicine, University of Bergen and Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
1. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. Bmj. 2019;366:l4185. doi: 10.1136/bmj.l4185
2. Högberg U, Lampa E, Högberg G, Aspelin P, Serenius F, Thiblin I. Infant abuse diagnosis associated with abuse head trauma criteria: incidence increase due to overdiagnosis? Eur J Publ Health. 2018;28(4):641-6. doi:10.1093/eurpub/cky062
3. Högberg U SR, Wester K, Högberg G, Andersson J, Thiblin I. Medical diagnoses among infants at entry in out-of-home care: A Swedish population-register study. Health Science Report. 2019;e133:1-12. doi: 10.1002/hsr2.133
4. Högberg U, Andersson J, Squier W, Högberg G, Fellman, Thiblin I, Wester K. Epidemiology of subdural haemorrhage during infancy: a population-based register study. PLoS One. 2018. doi: 10.1371/journal.pone.0206340
5. Högberg U, Andersson J, Högberg G, Thiblin I Metabolic bone disease risk strongly contributing to long bone and rib fractures during early infancy: A population register study PLoS One. 2018;13(12):e0208033. doi: 10.1371/journal.pone.0208033
6. Elinder G, Eriksson A, Hallberg B, Lynoe N, Sundgren PM, Rosen M, et al. Traumatic shaking: The role of the triad in medical investigations of suspected traumatic shaking. Acta Paediatr. 2018;107 Suppl 472:3-23. doi:10.1111/apa.14473
Competing interests: No competing interests