Expert consensus on cognitive biases affecting child physical abuse evaluations in pediatric emergency medicine: A modified Delphi study

Child abuse causes significant morbidity and mortality, yet the diagnosis can be missed. Little is known regarding which cognitive biases influence diagnostic errors in child abuse evaluations in Pediatric Emergency Medicine (PEM). To obtain consensus on important cognitive biases that affect accurately diagnosing child physical abuse in the emergency department. and setting: A multidisciplinary expert panel of 15 nationally recognized experts in pediatric emergency medicine or child abuse pediatrics (CAP). A modified Delphi study was conducted, including 3 iterative survey rounds of expert opinion and statistical summary of survey responses for an a priori goal of 7-9 cognitive biases. Thirty-two cognitive biases were compiled following review of a sentinel article with corresponding PEM-specific vignettes and definitions. Using a Likert scale, participants rated the importance and frequency of each cognitive bias in physical abuse evaluations. To obtain consensus, the lowest 1/3 of the median importance scores were eliminated for each round. Median frequency scores were used as a tiebreaker between cognitive biases, if required. Thirteen of 15 (86.6%) experts completed the Delphi process, agreeing on 9 most important cognitive biases in child physical abuse evaluations: anchoring bias, ascertainment bias, confirmation bias, framing bias, fundamental attribution error, outcome bias, premature closure, unpacking principle, and visceral bias. Each cognitive bias received a final median score of 7 for importance. Understanding the most important cognitive biases in child physical abuse evaluations in PEM may supplement medical education in reducing misdiagnosis of child abuse. • Poor clinical reasoning and lack of knowledge both increase diagnostic errors • A Delphi method obtained consensus of important cognitive biases in physical abuse • Understanding cognitive errors in child physical abuse may reduce misdiagnosis