Beyond ‘diagnostic error’: an ethnography of resilient behaviours and system adaptations in paediatric outpatient diagnosis
Christina L Cifra, Katherine Melton, Kathleen E Walsh, Ellen A Lipstein, Alisa Khan, Alyna T Chien, Irit R Rasooly, Trisha L Marshall, Patrick W Brady, Samira Ahmed, Kimberly Asitimbay, Alexander Fidel, Tamaki Hashiramoto, Ruby Hyland-Brown, Nolan Joyce, Brynn Telenko, Sara L Toomey, Christopher P Landrigan, Ken CatchpoleBackground
Improving paediatric diagnosis by addressing errors (Safety-I) is insufficient for diagnostic excellence. Resilience engineering’s approach to understanding adaptations to achieve success in everyday work may elucidate how individuals and systems manage diagnostic complexity to achieve diagnostic success (Safety-II). Our objective was to characterise resilience-promoting behaviours of patients/families and clinicians and resilient organisational properties in outpatient diagnosis of children with medical complexity.
Methods
This ethnographic study included observations of outpatient visits and semistructured interviews of parents/guardians and providers. Resilience engineering frameworks informed data collection and analysis. We prospectively sampled patients <18 years old with medical complexity presenting with acute problems in clinics at three academic health systems from 25 January 2024 to 26 February 2025. We qualitatively coded field notes and interview transcripts, focusing on individual resilient behaviours and instances of organisational resilience. We identified resilience themes using directed content analysis and described the frequency and types of resilience concepts.
Results
We observed 258 unique resilience-promoting behaviours and organisational properties in 31 of 33 (94%) patient visits, with an average of 7.8 resilient behaviours/properties per visit. Of these, 178 (69%) reflected patient/family and clinician activities to promote diagnostic resilience and 80 (31%) reflected organisational resilience relevant to diagnosis. The most frequently identified resilience behaviours/properties were anticipation (prediction of future events and contingency planning), monitoring (vigilant observation for clinical evolution), robustness (comprehensiveness and redundancy in the diagnostic process) and graceful extensibility (stretching resources to meet diagnostic needs).
Conclusions
Resilient behaviours by patients/families and clinicians and resilient organisational properties supporting diagnostic excellence can be prevalent in outpatient paediatrics for children with medical complexity. Future research should characterise diagnostic resilience’s impact on diagnostic safety and patient/family outcomes.