Preventing Errors in Pediatric Primary Care

A UF Health pediatrician participates in a national study working to reduce misdiagnoses in children and teens.

By: Sarah Miller

A UF pediatrician is working to stop a common problem that harms thousands of children across the country every year. Not enough is known about diagnostic errors in pediatric primary care, including how they occur or how to prevent them. In an effort to improve this, UF Health Pediatrics – San Jose participated in a first-of-its-kind quality improvement project aimed at reducing misdiagnoses related to elevated blood pressure, delayed follow-up to labs and missed opportunities to diagnose adolescent depression.

“Being involved in the quality improvement initiatives project was a great motivator,” said Pamela Lindor, MD, medical director at UF Health Pediatrics – San Jose. “It provided structure, tools and support to help our practice set goals and make sustainable changes to improve care.”

The two-and-a-half year study was sponsored by the American Academy of Pediatrics. Practice Improvement Network Reducing Diagnostic Errors in Primary Care Pediatrics, or Project RedDE!, included a select group of clinical teams that have 30 well-visit encounters with children 11 years old and older, as well as 30 well-child visits with patients 3 years old and older per month. While participating in the national project, Lindor saw a dramatic increase in the identification of adolescent patients with depression.

“Before participating in the study, we weren’t doing regular screening for depression in young adolescents,” Lindor said. “Now there is a consistent procedure to screen for depression starting at age 11 at every annual well check.”

Patients screened for depression are given a questionnaire that is evaluated using a scoring guideline. Their answers also provided initial information the providers used to talk with the patient and family to get a full assessment. If there is violence in the home, high amounts of stress or financial difficulties, the provider can discuss the connection between these factors and depression.

“It’s important to reassure parents on the routine nature of the screening and open the discussion about potential issues that may be developing,” Lindor said.

Screening at a younger age also gives children and teens practice with thinking and talking about these issues. Some of the screening questions may seem predictable in diagnosing depression, such as whether they have recently felt hopeless or had thoughts about self-harm. Some questions are less expected and ask the child if they have been moving or speaking slowly, enough to be noticed by others. The opposite is also asked — if they have noticed extra energy or are moving more than usual. These indicators may signal cause for concern.

“It’s important for adolescents to develop coping skills, and social or family stress can interfere with this development,” Lindor said. “Good sleep habits, as wells as a healthy diet and regular exercise can improve coping skills and decrease levels of depression.”

The treatment a patient receives varies based on their answers. Mild depression can typically be treated in the office. Counseling with a professional at school or religious organization may be recommended for moderate depression. Patients with severe depression may be referred to a psychologist or psychiatrist. If the questions on suicide or functionality raise enough concern, emergency mental health services are initiated. All recommendations are made as soon as possible to better serve the patient and family.

“There is value in this type of early screening because we are able to identify patients that may have been missed without this process,” Lindor said. “Data collection through research projects like Project RedDE! pinpoint where changes need to be made to ensure errors are the exception and not the rule.”