91 - Resilient Behaviors and System Adaptations Toward Diagnostic Excellence in Pediatric Outpatient Care

Publication Number: 4089.91

Christina L.. Cifra, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Katherine Melton, Rhode Island Hospital/ Hasbro Children's Hospital, Boston, MA, United States; Ellen Lipstein, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Alisa Khan, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States; Alyna T.. Chien, Boston Children's Hospital, Boston, MA, United States; Irit R. Rasooly, Childrens Hospital of Philadelphia, Bala Cynwyd, PA, United States; Trisha L. Marshall, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Patrick W. Brady, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Samira Ahmed, Boston Children's Hospital, Winter Haven, FL, United States; Kimberly Asitimbay, Boston Children's Hospital, West Yarmouth, MA, United States; Alexander Fidel, Children's Hospital of Philadelphia, Brooklyn, NY, United States; Tamaki Hashiramoto, Boston Children's Hospital, Boston, MA, United States; Ruby Hyland-Brown, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Nolan Joyce, Boston Childrens Hospital, East Bridgewater, MA, United States; Brynn Telenko, Boston Children's Hospital, West Chester, PA, United States; Christopher P. Landrigan, Boston Children's Hospital, Boston, MA, United States; Kathleen E. Walsh, Boston Children's Hospital, boston, MA, United States; Ken Catchpole, Medical University of South Carolina, Charleston, SC, United States

Background: Efforts to improve pediatric diagnosis by addressing diagnostic errors (Safety-I) are insufficient to achieve diagnostic excellence. A resilience engineering approach, which aims to understand the flexibility and adaptations necessary to achieve success in everyday work, may help us understand how individuals and systems manage diagnostic complexity and uncertainty under dynamic conditions to achieve diagnostic success (Safety-II).

Objective: To characterize resilience-promoting behaviors of patients/families and clinicians, and resilient organizational properties in pediatric outpatient diagnosis.

Design/Methods: We conducted a mixed methods study using ethnography including direct observations of pediatric outpatient visits and semi-structured interviews of parents/guardians and providers. Observation and interview guides were developed based on integrated patient safety, diagnosis, communication, and resilience engineering frameworks. Using purposive sampling, we included patients < 18 years old with medical complexity seen for acute problems in clinic at 3 academic health systems over 13 months (1/25/2024-2/26/2025). Field notes and interview transcripts were qualitatively coded focusing on resilient clinician behaviors and organizational resilience. Data per patient encounter were dual coded with disagreements resolved by consensus. Content analysis was used to identify resilience themes and resulting quantities were reported using descriptive statistics.

Results: We observed 258 unique resilience-promoting behaviors and resilient organizational properties. Resilience was demonstrated most frequently via anticipation (proactive prediction of what may happen 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) (Table 1). We observed 178 (69%) patient/family and clinician activities promoting diagnostic resilience and 80 (31%) organizational resilience features relevant to diagnosis. Behaviors/properties were exhibited in 31 of 33 (94%) visits, with a mean of 7.8 unique resilient behaviors/properties per visit (Figures 1&2).

Conclusion(s): Resilient behaviors by patients/families and clinicians and resilient organizational properties supporting diagnostic excellence are prevalent in outpatient pediatrics. Future research should characterize diagnostic resilience's impact on diagnostic safety and patient/family outcomes.

Table 1. Representative Quotes Illustrating Most Common Resilience-Promoting Behaviors and Resilient Organizational Properties


Figure 1. Unique Resilient Behaviors Per Patient Encounter Across Different Data Sources


Figure 2. Unique Instances of Organizational Resilience Per Patient Encounter Across Different Data Sources