A closed claim study indicates that liability risks in pediatrics vary with the age of the patient. It also suggests the need for more involvement by parents and guardians.
• The median indemnity was $250,000.
• Some parents do not understand what information is important to communicate.
• Provide questionnaires before the appointment to obtain better information.
Pediatricians and other physicians treating young patients face different risks depending on the age of the patient, according to a recent closed claim study by a professional liability insurer. The review also suggests that physicians should more actively engage parents and guardians in the care of the child.
The Doctors Company, based in Napa, CA, analyzed 1,215 claims involving pediatric patients that were closed from 2008 through 2017. They involved physicians in 52 specialties and subspecialties, with a median indemnity payment of $250,000, and a median expense to defend of $99,984.
Neonates had the highest mean indemnity of $936,843 and the highest median indemnity payment of $300,000. This group also had the highest mean expense, $187,117, and the highest median expense, $119,311. (The study is available online at: https://bit.ly/2GYWTFa.)
The report notes that 3% of pediatric claims were filed more than 10 years after the injury, indicating the value of good documentation.
Risks Change as Child Grows
The closed claim review clearly shows that the liability risk for physicians varies significantly by the patient’s age, says Darrell Ranum, JD, CPHRM, vice president, Department of Patient Safety with The Doctors Company.
“Children at different stages of their development and maturity have different vulnerabilities. Neonates are subject to trauma from delivery, and they also are vulnerable to certain conditions like elevated bilirubin — which, if gone untreated, can result in brain damage,” Ranum says. “That makes it important to communicate to the parents when they take the baby home that they need to have the new baby visit quickly and they need to recognize that if the baby turns green, they should get the baby seen as soon as possible.”
Newborns also are vulnerable to infectious diseases, and they may have unrecognized allergies, he notes. As the child grows older, the nature of their injuries and illnesses change. Young children are susceptible to falls and trauma from their increasing mobility and exploration, whereas teenagers are subject to injuries from car accidents and sports, as well as communicable diseases.
“At each stage, they are exposed to different kinds of risks, and that means the challenges faced by their physicians also change over time,” Ranum says.
Communication Is Vital
The study emphasizes the importance of good communication with parents, Ranum says. There were a few cases in which children were born into families with a history of bleeding disorders, but the parents did not recognize that as important information to pass on to the physician, he says.
“Sometimes, if the child is taken to surgery without that knowledge, there can be a problem. Improving communication can minimize that risk,” Ranum says. “Or the patient could have inherited problems like sickle cell anemia. All of those problems need to be communicated to the physician, and unfortunately in some cases they are not.”
Improving communication with parents can be challenging. Physicians may deal with parents who have little or no insight on anatomy, physiology, or disease states, Ranum says.
“Parents are trying to communicate on behalf of the child, trying to convey what the child cannot say for himself or herself, which is already a difficult task. The child can’t say what hurts or what happened, and the parent may be limited in how they can convey even the minimal information they have about the problem,” Ranum says. “If we recognize those limitations, maybe we can do things that help the parents be more effective advocates for their children.”
One strategy is to provide parents with questionnaires and other documents before the appointment — not when they arrive with a fussy child and siblings in tow — that will prompt them to think about their child’s history and current condition, Ranum says. They might even be prompted to ask grandparents and others for information that could be useful.
“Sometimes, physicians are working in the dark if they don’t have this information because the parents don’t have it or they don’t recognize the clinical significance of this information they should be sharing,” Ranum explains. “Prompting parents ahead of an appointment can help parents be a more effective historian for their child and help the physician move through the diagnostic process.”
Physicians also can encourage parents to keep a diary of their child’s illness. Many times, a physician will ask if the child has been sick since the last doctor visit, and the parents have difficulty remembering when the child had an ear infection or the flu and details of the illness, he says.
“It’s also important for physicians to recognize the disparity in knowledge and clinical issues. Physicians have to be very patient,” Ranum says. “We’ve seen data on how quickly doctors interrupt patients and parents when they’re trying to convey their clinical concerns, so physicians really need to hold on and give parents and children a chance to express themselves.”
When the physician is communicating with the parent, it can be challenging to communicate the treatment plan and the need for particular tests. Ranum recommends the “Ask Me 3” program from the Institute for Healthcare Improvement, which encourages physicians to use cards or other prompts for asking three main questions: “What is my main problem? What do I need to do? Why is it important for me to do this?” (Resources and more information on the program are available online at: https://bit.ly/2HHqbFm.)
“You can encourage them to ask those questions and write down your responses. That gives the parent something to take home with them and guide them in the future,” Ranum says. “A lot of times, parents just don’t know the clinical significance of some signs and symptoms, so having something to take home that reminds them of your conversation can be helpful.”
Ranum points out that it also is important to train staff members in how to answer questions from parents, who may ask the staff member who answers the phone about a worrisome situation only to be told to bring the child in if it seems serious.
“In some situations, these children can get very sick very fast, so physicians have to prepare their staff to know what kind of concerns should prompt physician review or telling the patient to bring the patient in immediately,” Ranum says. “It’s those fine lines of communication that can make the difference in outcomes for some of these patients, particularly postoperatively.”
Good Data on ED Visits
There are not many studies regarding pediatric malpractice claims, especially for children seen in the ED, notes Phyllis L. Hendry, MD, FAAP, FACEP, professor of emergency medicine and pediatrics and assistant chair for research in the Department of Emergency Medicine at the University of Florida College of Medicine in Jacksonville. Most ED-focused studies lump children in with adults in discussing risks, and pediatric studies include a high percentage of newborn and neonatal cases, she says.
“This study is important because it focuses exclusively on children and provides detailed data on the top 10 specialties named as defendants, including emergency medicine physicians,” she says. “In the U.S., about 27% of ED visits are for children from zero to 18 years of age. Caring for children presents unique risks and challenges and includes dealing with a wide range of developmental and physiologic stages while communicating with parents or caregivers.”
The case studies in the report demonstrate that problems are not usually caused by physician lack of knowledge, Hendry says. Instead, most errors are caused when things fall through the cracks due to system issues, including communication.
“You see in this research that it’s not one magic bullet that will cure everything, and it’s not one diagnosis that we’re missing,” Hendry says. “It’s multifactorial.”
The closed claim study raises a good question regarding how to make parents and caregivers better partners in the medical process, Hendry says.
“Emergency medicine physicians and their teams must be skilled at gathering a lot of new data in a rapid manner while establishing a communication bond and sense of trust with a worried parent or caregiver they have just met,” she says. “There is a skill to addressing a parent’s fear the first time their child is significantly ill or injured or being given a bad diagnosis.”
Red Flags for Pediatrics
Hendry says the study results bring to mind red flags and high-risk scenarios requiring additional time or scrutiny when treating children. She cites the following examples:
• Children who return to the ED or a doctor’s office for more than two visits;
• Children who return with post-surgical complaints or complications;
• Parents or families with limited English proficiency, disabilities, chronic medical conditions, or mental illness;
• Unimmunized children;
• High-risk diagnoses or chief complaints such as testicular torsion or fever in an infant less than two months of age.
The study also draws attention to errors that are connected to test results, such as lost results, failure to inform physicians of critical test results, or not understanding normal pediatric lab value variation by age.
“These all relate to system issues,” Hendry says. “Having a clear call-back system and policies for reviewing diagnostic test results is key to preventing these system errors. It is important to always confirm the best phone number whereby medical staff can reach the parent to report abnormal results or schedule follow-up appointments after an emergency department or clinic visit.”
Clear Policies Necessary
The closed claim study shows that system failures and communication problems are among the top reasons for patient harm, as they are in all malpractice suits, says Arthur Cooper, MD, chief of pediatric surgery at Harlem Hospital Center in New York City.
This finding reiterates the need for clear policies and workable procedures that ensure tracking of test results and adequate exchange of information between the physician and the patient or patient’s family, he says.
“An interesting finding in this study is the relatively low frequency of claims involving children that arise from the emergency department. Most emergency medicine physicians feel that their decision-making is constantly under the microscope, so to speak,” Cooper says. “The finding that only 6% of total claims involve emergency medicine does not appear to support this feeling.”
Cooper says his experience has shown that pediatricians tend to be especially solicitous of patient and parent input, but he also is concerned that growing pressure to see more and more patients can interfere with that.
“When there is an employer putting pressure on you to see more patients every day, that can create a dilemma for the physician who wants to nurture that doctor-patient relationship and establish good communication,” Cooper says. “This can be especially damaging in pediatrics, where the parent is so eager to help the child but may need more time to accurately convey those concerns and all the relevant information.”
• Arthur Cooper, MD, Chief of Pediatric Surgery, Harlem Hospital Center, New York City. Phone: (212) 939-1000.
• Phyllis L. Hendry, MD, FAAP, FACEP, Professor of Emergency Medicine and Pediatrics, University of Florida College of Medicine, Jacksonville. Phone: (904) 244-4986. Email: firstname.lastname@example.org.
• Darrell Ranum, JD, CPHRM, Vice President, Department of Patient Safety, The Doctors Company, Napa, CA. Phone: (800) 421-2368.