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Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

CiteScore 2018: 0.69

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

Rena T. Kasick
  • Corresponding author
  • Department of Pediatrics, Division of Hospital Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Jennifer E. Melvin / Sajithya T. Perera / Michael F. Perry / Joshua D. Black / Ryan S. Bode / Jonathan I. Groner / Kelly E. Kersey / Brett G. Klamer
  • Biostatistics Resources, Nationwide Children’s Hospital, Columbus, OH, USA
  • Center for Biostatistics, The Ohio State University, Columbus, OH, USA (B.G. Klamer) (S. Bai)
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  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Shasha Bai
  • Biostatistics Resources, Nationwide Children’s Hospital, Columbus, OH, USA
  • Center for Biostatistics, The Ohio State University, Columbus, OH, USA (B.G. Klamer) (S. Bai)
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  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
/ Richard E. McClead
Published Online: 2019-11-02 | DOI: https://doi.org/10.1515/dx-2019-0054



Pediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months.


We reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July–December 2017; 101 charts were reviewed post-intervention, January–June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a ‘complete’ DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric.


At baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a ‘complete’ DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41–2.47, p = 0.73), but attending-documented DDx did not improve (2.85–2.82, p = 0.88).


We demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.

Keywords: cognitive error; diagnostic time-out; differential diagnosis; quality improvement


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About the article

Corresponding author: Rena T. Kasick, MD, Assistant Professor, Department of Pediatrics, Division of Hospital Pediatrics, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA

Received: 2019-07-09

Accepted: 2019-10-17

Published Online: 2019-11-02

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: All phases of this study were supported by a grant through the Betty and Gordon Moore Foundation through collaboration with the Institute for Healthcare Improvement and the Society for Diagnosis in Medicine.

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organizations (above) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Citation Information: Diagnosis, 20190054, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2019-0054.

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