Diagnostic Errors in Children with Bacterial Osteomyelitis

BACKGROUND: Clinical evidence for improving diagnostic accuracy in pediatric medicine is still scarce. Septic osteomyelitis is sometimes challenging for physicians to diagnose. The aim of this study was to improve patient care through identifying the incidence and reasons for errors in the diagnosis of bacterial osteomyelitis in pediatric patients. METHODS: We retrospectively identified patients younger than 16 years with acute or chronic osteomyelitis at Tokyo Metropolitan Children's Medical Center between April 2010 and September 2017. We extracted data on patient demographics, clinical course, symptoms, locus of the lesions, and diagnosis at presentation and discharge. The patients were categorized into the misdiagnosis and non-misdiagnosis groups following a review by two pediatricians. Misdiagnosis was defined as a difference between the initial and discharge diagnosis. The factors in the two groups were compared, and the types of error in the misdiagnosis group were examined. RESULTS: In total 71 patients were enrolled. The median age and proportion of boys was 7.6 years (IQR, 1.4-11.2 years) and 66%, respectively. Misdiagnosis occurred in 27 patients (38.0%). Precedent antibiotic use was independently associated with misdiagnosis (P = 0.044). A cognitive error was observed in 88.3% of the misdiagnosis group. The median number of types of error per case was 2.0 (IQR, 2.0-3.0). CONCLUSIONS: The misdiagnosis of septic osteomyelitis in pediatric patients was common and chiefly caused by cognitive errors. Eliminating cognitive errors in diagnosis is highly likely to improve the care of patients with osteomyelitis.