Pediatrics: A unique and volatile risk

© 2011 American Society for Healthcare Risk Management of the American Hospital Association

Published online in Wiley Online Library (wileyonlinelibrary.com) • DOI: 10.1002/jhrm.20084

AMERICAN SOCIETY FOR HEALTHCARE RISK MANAGEMENT • VOLUME 31, NUMBER 2 19

By Paul Greve, JD, RPLU, DFASHRM

Clinical Risk Management

Pediatrics: A unique and volatile risk

Pediatric risk is both unique and volatile. Children are more vulner-able when treated in any healthcare environment, but especially in the acute care setting. Children with chronic healthcare conditions are more challenging to treat and more susceptible to medical errors. Despite marked improvement in the national medical malpractice environment, the most volatile claims involve severely injured patients under age eighteen and especially those patients in the first year of life.

This article provides the context of pediatric care in reviewing the demographics of children and the healthcare delivery system. The unique factors of pediatric care that create increased risk are also reviewed. Low frequency/high severity claims involving children are discussed in detail as well as physician claims in the specialty of general pediatrics. Risk management solutions for pediatric issues are proposed.

INTRODUCTION

The current national medical malpractice environment is the best it has been and the most stable since the advent of the first malpractice crisis in 1975. This stability is attributable in great part to low claim frequency and moder-ate severity trends. Risk management and patient safety initiatives have also contributed to this improvement. However, the most volatile healthcare profes-sional liability cases to defend involve severely injured children in obstetrics and pediatrics scenarios. Some of the largest verdicts and settlements in the United States over the past 5 years have occurred in nonobstetric pediatric cases. In many instances, they exceed $5 million (see Exhibit 1).

The emotional impact on a jury of a severely injured child in a medical mal-practice case is almost always a huge hurdle to overcome. This is just one pri-mary factor resulting in multimillion-dollar verdicts and settlements. Another primary factor is improved medical care for severely injured children, thus resulting in more expensive care over more years. Life care plans for children are very costly. Large verdicts in pediatric cases can result, even in states with caps on pain and suffering like Wisconsin and others. In states without non-economic damage caps like New York, New Jersey, Pennsylvania, Illinois, and Florida, verdicts and settlements can exceed $10 million.

The economy is a factor as well in increased claim costs for cases involving chil-dren. With low interest rates, the use of annuities is less desirable. A structured settlement is not as cost-effective or as palatable to plaintiff ’s attorneys in

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JOURNAL OF HEALTHCARE RISK MANAGEMENT • VOLUME 31, NUMBER 2 DOI: 10.1002/jhrm20

pediatric cases. Plaintiff ’s attorneys have also become quite creative in finding ways that will drive up the cost of life care plans for injured children.

This article will provide an overview of recent pediatric lia-bility trends. The overlap between quality improvement and risk management is the elimination of substandard care. This cannot occur unless there is an understanding of internal risk management trends as well as national claims and medi-cal error trends. This article will focus on national pediatric claim trends. The demographics of children in the healthcare delivery system also affect risk management strategies.

Children: Demographics and the healthcare delivery system

The demographic characteristics of children profoundly affect the healthcare delivery system and risk management and patient safety programs. The number of children, their economic circumstances, family and social environ-ment, and special needs for chronic illness and disability all shape the delivery of pediatric care.

As of 2009, there were 74.5 million children in the United States, 2 million more than in 2000. While the numbers of children have been decreasing as a percent-age of the overall population since the end of the Baby Boom era (1964), children 0 to 17 years of age now com-prise 24% of the population. This number is expected to remain stable through 2050, although the country’s increasing racial and ethnic diversity will be reflected in that, by 2023, less than half of all children are projected to be white, non-Hispanic.(1)

In 2008, 19% of children, more than 14 million, lived in poverty, an increase of 1 percent from 2007.(2) The recent economic downturn suggests that this number has continued to grow and is estimated to be at 21% in 2010. Job losses and declines in real income have factored into the decline of many children’s quality of life.(3)

Sixty-seven percent of children lived with two married parents in 2008, a 10% drop since 1980. In 2007, 40% of all births were to unmarried women, the highest per-centage in history.(4)

One bright spot in the demographic characteristics of children is that 90% of children had health insurance in 2008. This greatly facilitates the delivery of effective pedi-atric care, but still leaves many without.

The percentage of children receiving public health insur-ance in some form increased from 31% to 33% from 2007 to 2008.(5)

Another bright spot is the slightly decreased numbers of infants born preterm or with low birth weight, from 12.8% in 2007 to 12.7% in 2008. These children are at high risk for early death and long-term developmental and health problems.

However, more children had chronic disease (obesity, asthma, learning disability, etc) in 2010, and the rate has more than doubled over the past 2 decades.(6) Obesity is a major contributor to this high rate of chronic disease and is a major problem for children ages 6 to 17, with 19% of all children determined to be obese in 2008.(7) Longer-term survival of children born prematurely and those with

Exhibit 1:Recent Large Pediatric Losses

Location Date Award Pediatric IssueLos Angeles 12/09 $5M (s) Kernicterus. Bilirubin levels alleged not timely reported by lab.Chicago 11/09 $22.3M (v) Infant’s leg required amputation following delays and alleged negligent

care.Tampa/St. Petersburg 10/09 $11.1M (v) Infant incurred brain damage; alleged failure to treat dehydration.Madison, WI 4/09 $17.3M (v) Alleged improper performance of a splenectomy on 8-year-old; brain damage.Kansas City 3/09 $12.1M (v) 8-year-old alleged as improperly diagnosed; arteriovenous malformation

hemorrhaged; quadriplegia.Wisconsin 7/08 $35.1M (v) Alleged negligent performance of transfusion (air in line); 2-week-old

infant; quadriplegia.Florida 4/08 $38M (v) Alleged failure to diagnose ROP; blindness; twins.Georgia 3/08 $24.5M (v) Alleged failure to monitor child’s leg for blood flow problems; amputation

of 14-year-old boy’s leg.Los Angeles 7/07 $15.4M (v) Alleged failure to diagnose and treat kernicterus.Philadelphia 11/06 $20M (v) Infant with ROP alleged lost to follow-up after NICU discharge; blindness.v = Verdicts = Settlement


DOI: 10.1002/jhrm AMERICAN SOCIETY FOR HEALTHCARE RISK MANAGEMENT • VOLUME 31, NUMBER 2 21

diseases such as sickle cell anemia and cystic fibrosis may be driving these higher rates of chronic disease.

One author says that “… the relatively small group of children with a chronic illness likely will account for an increasingly large proportion of all serious illness and healthcare expenditures in childhood.” Chronic disease now accounts for more than 90% of all pediatric medical causes of death, even excluding the deaths of children less than 1 year of age and deaths from trauma.(8)

Access to pediatric subspecialist physicians has become a healthcare system barrier to timely care for children with chronic or complex disease presentations. A shortage across many pediatric subspecialties is resulting in children lost to care, delayed appointments, or referrals to other institu-tions, often at great inconvenience and expense to the par-ents.(9) Waiting 3 to 7 months for pediatric subspecialist appointments is not uncommon.

There have been dramatic improvements in pediatric care in recent decades. These improvements in care have reduced mortality and also helped prolong survival of more chil-dren with complex health conditions well into adulthood, depending on the underlying conditions. But many children who would not have survived now do so with significant neurological and physical impairment.(10) They are a challenge to treat whenever, wherever, and in whatever setting they present. They are also more prone to medical errors, as noted below.

These demographic factors not only affect the delivery of healthcare to children but also affect risk manage-ment and patient safety strategies.

The inability to pay for care and local availability of pedi-atric services may result in delayed treatment, leading to increased morbidity and mortality.

Parental communication barriers due to language and socioeconomic factors may affect pediatric outcomes when discharge instructions are not understood. This can result in the inadequate parental assessment of changes in a child’s condition and the need for a return to the emer-gency department, clinic, or physician’s office.

Demographic factors may increase pediatric risk. Risk management and patient safety strategies must take into account the issues raised by the demographics of children in the US healthcare delivery system.

Pediatrics: A unique and volatile risk

Pediatric risk is both unique and volatile. Children have limited ability to communicate with caregivers, if at all.

Caregiver–provider communication problems are exac-erbated if caregivers have language barriers, knowledge deficits, and limited parenting skills. Children’s limited intellectual capacity and judgment may result in increased risk of injury in a healthcare setting. Children require age- and size-appropriate equipment and medications. Improving patient safety and risk management programs involving children requires taking into account these areas of vulnerability in pediatric settings.

Woods et al. published an overview of risk factors and patient safety in children that discussed what risk factors are present in pediatric patient populations. These included such factors as children’s size, physiology, and development. In their study, the aspect of pediatric care that caused the most frequent patient safety issues was medication adminis-tration, followed by surgical and nonsurgical procedures.(11)

A study published in 2005 on adverse events in children found that adverse events occurred in children in 1% of the pediatric hospitalizations and that 60% of these events

were preventable. This translates into 70,000 hospitalized children experi-encing an adverse event.(12) There are studies that suggest the rate may be even higher.

A study published in 2003 found that the rate of medical errors for hospital-ized children ranged from 1.81 to 2.96 per 100 discharges. This study also found that chronically ill children or those dependent on medical technol-ogy “had significantly higher rates of … medical errors,” and children whose cases involved medical errors “had significantly higher death rates” and longer hospitalizations. The researchers found that the three leading categories

for adverse events in children were birth related, diagnos-tic related, and system related. Children were much more likely (1.35 times more likely) to have a diagnostic-related preventable event than adults.(13)

Medication administration in children is complex and presents a significant risk to pediatric patient safety. A US Pharmacopeia study in 2002 found that 6% of medica-tion errors in children cause harm versus 2.4% for all other ages. There is a lack of standardized dosing regimens for children. Many medications do not come in pediatric doses, thereby creating the chance for errors in calculating the correct dosages. Lack of accurate patient weight infor-mation is often a contributing factor.(14) The requirement to customize medication dosages for children results in more steps in the process, leading to more chance for error.

The rate of error for potential serious medication errors is three times more frequent in pediatric patients. Very young children are particularly “vulnerable to dangerous 10-fold errors in dosing.”(15)

There have been dramatic

improvements in pediatric

care in recent decades.



The highly publicized incidents with heparin involving neonates in Indianapolis and Los Angeles fall into this category.(16, 17)

Pediatric risk is volatile. Injuring a child is typically often more expensive for claim resolution than injuring an adult primarily due to improved healthcare and the resultant long-term survival. Sympathy is a major factor in the consideration of taking cases to trial, as is the cost of any significant life impairment and the requisite payment to make the patient and family whole.

The Ohio Department of Insurance (ODI) releases an annual claims report of all medical malpractice closed claims in the state and reported to ODI, as is mandated by statute. In 2009, there were a total of 3344 claims filed, with an average indemnity paid per claim of $322,158. But of the 152 claims involving infants (less than 1 year of age), the average indemnity paid was $974,297. For the 152 claims paid involving minors (ages 1 to 17), the average indemnity paid was $531,802.(18)

Low-frequency/high-severity claims by condition

Four types of recurring pediatric cases in the category of high frequency/low severity are particularly problematic: meningitis, malrotation of the bowel/volvulus, retinopa-thy of prematurity (ROP), and kernicterus. Verdicts and settlements in these cases often are in multiple millions of dollars. Many of these cases are settled confidentially for large amounts. The trial bar seeks out these high-damage cases through diverse advertising strategies, especially through the Internet.(19)

Meningitis and malrotation of the bowel cases frequently involve misdiagnosis and/or delayed treatment. Children presenting with fevers or abdominal pain can be notori-ously difficult to diagnose. These cases can involve errors in judgment and errors in communication, as well as system breakdowns, such as failure to manage critical test results. Pediatricians historically are especially vulnerable to liability from telephone communications with parents according to Physician Insurers Association of America (PIAA) Closed Claim data on that specialty.(20)

However, ROP cases and kernicterus cases often involve system/communication breakdowns. These systemic errors result in neonates, not receiving requisite initial eye examinations or subsequent follow-up examinations (ROP); or initial and follow-up testing and/or treatment for jaundice/highly elevated bilirubin levels in the blood (hyperbilirubinemia), resulting in kernicterus.

MeningitisMeningitis is an inflammation of the brain lining, known as the meninges. Of the four conditions causing low-frequency/high-severity claims in pediatrics, meningitis is foremost because this condition occurs more frequently in

children than the other three and is perhaps the most expen-sive to resolve as to both indemnity and claims expense.

Meningitis claims are expensive due to the high cost of life care plans for a neurologically impaired child. Meningitis death claims are also expensive and difficult to defend.(21) A study published in 2007 on PIAA menin-gitis malpractice claims found that one-third of the cases involved the death of the child.(22)

Unlike ROP and kernicterus, there are very few widely published and accepted guidelines on the treatment of febrile children, especially infants. Reasonable providers can come to different conclusions on whether or not to subject an infant to a spinal tap based on the clinical pres-entation of the patient, the cost, the risk of complications (eg, a contaminated tap), and a fully informed parental consent.(23)

Meningitis is a difficult diagnosis. Many children present with fever, but meningitis symptoms are often confus-ing and quite subtle. The symptoms of other illnesses are often present and can make it difficult to distinguish a presentation of meningitis. The symptoms can sometimes be quite evident or very few. A recent article stated that “… the most accurate combination of clinical features to raise or lower suspicion of meningitis is still unclear. …”(24)

The patient is usually too young to verbalize head-ache or neck pain. Bacterial strains, the most virulent, can often progress rapidly, providing a very narrow window within which to provide effective therapeutic intervention.(25)

According to Selbst et al., “… missed meningitis is the most common diagnosis involved in pediatric emergency malpractice claims. …”(26) Given the difficulty of diag-nosing this condition, this is not surprising.

The PIAA issued a special report on meningitis claims in 2000. It looked at 724 meningitis claims over a 15-year time frame from January 1, 1985, to December 31, 1999. Its major findings are still instructive, including:

The initial contact by the patient (or caregiver) was via • the telephone in roughly 18% of all cases. These claims were more than 2 times more expensive to resolve than claims that occurred in the physician’s office.

A physician’s delayed response times to patients and • caregivers contributed to the delay in diagnosis of men-ingitis. Delayed response times also resulted in higher indemnity payments.

The patient often was incorrectly diagnosed with a viral • disease such as an ear infection or upper respiratory infection.(27)

The type of meningitis most commonly involved in these • claims was the bacterial strain, at 86.3% of all cases.



Young patients were most often involved, thus resulting in significant damages and high indemnity, with more than 60% of all patients age 2 or under.(28)

Risk management strategies for meningitis include care-ful listening to caregivers about changes observed in an infant; providing clear follow-up instructions including symptoms that require immediate medical care; thorough documentation of all communication and observations; maintaining a high index of suspicion for meningitis when evaluating young children with flulike symptoms; evaluation, referral, and/or admission of patients present-ing with any symptoms indicating meningitis until it has been ruled out.(29)

Volvulus/malrotation of the bowelLike meningitis, volvulus/malrotation of the bowel can be a difficult condition to diagnose in children, especially outside the neonatal period, for many reasons. Not every child with malrotation of the bowel develops volvulus. But an article in a 2003 pediatric surgery publication stated, “Malrotation with its propensity for volvulus is truly a time bomb lying within.”(30)

Volvulus is defined as “a twisting of the intestine causing obstruction; if left untreated may result in vascular com-promise of the involved intestine.”(31) Volvulus, in effect, is a complication of malrotation of the bowel.(32)

Many times, the bowel will untwist spontaneously or the obstruction can occur intermittently, but if it does not, the consequences can be catastrophic (loss of blood supply to the bowel, resulting in necrosis and removal of the bowel, meaning a lifetime of dependency on parenteral nutri-tion[33]), and can even be fatal.(34) Volvulus with intesti-nal obstruction is a surgical emergency for children at any age, requiring rapid intervention. Thus, there is a critical need for a timely diagnosis. Surgical intervention restores blood supply to the bowel unless it is already necrotic.(35)

The most common presentation of this condition occurs during a child’s first year, especially in the neonatal period, but the condition can occur in older children and even adults. The condition occurs in males at twice the rate of females in the first year of life. Infants often present within the first week of life (often after hospital discharge[36]) with bile-staining vomit and an acute bowel obstruction. However, the clinical presentation is often muddled in that the patient may present with other symptoms such as diarrhea, shock, gastrointestinal bleeding, evidence of sepsis, and nonbilious vomiting.(37) Infants with this condition may have a normal initial abdominal examination in 50% to 60% of all cases.

Older infants can present with symptoms such as recur-ring episodes of stomach pain that may mimic colic. Older children can present with recurring symptoms of stomach pain, vomiting, or both, in addition to signs of malabsorp-tion and failure to thrive, but 25% to 50% of all adoles-cents with volvulus/malrotation are asymptomatic.(38)

Obtaining appropriate imaging studies is of great impor-tance for this diagnosis, but even with that, occasionally the radiologic findings may be very confusing based on anatomic variation.(39) This can lead to overdiagnosing the condition of volvulus and an unnecessary surgical pro-cedure. However, in the risk/benefit analysis, the known complications of such abdominal surgery are rarely cata-strophic, while the failure to timely intervene surgically just may be. It is not an easy evaluation to make when the symptoms of volvulus are not obvious.(40)

In terms of risk management, the pediatric presentation of malrotation with midgut volvulus is uncommon, but the pediatric practitioner should always be on guard for it due to its devastating potential.

It usually occurs in the first month of life, as sudden bil-• ious vomiting is an indication there is a significant proxi-mal bowel obstruction.

Physical exam and plain abdominal x-rays can both be • normal in the early stages.

Simultaneous consultations to radiology for an emergent • upper GI series and to surgery for an early status alert are imperative once this is suspected.

Bowel decompression via an NG tube with concurrent • intravenous hydration should be started immediately.

The healthcare team should minimize all delays to ensure • that the patient reaches the proper operating facility emergently to avoid a serious negative outcome.(41)

Retinopathy of prematurity (ROP)ROP is a progressive eye disease of the retinal blood ves-sels occurring in low-birth-weight premature infants. ROP occurs only in low-birth-weight neonates treated in level II or level III neonatal intensive care units (NICUs). The paramount issue for clinically managing ROP is timely identification of the disease and early treatment. Delays in either identification or treatment can be devastating in that the natural progression of the disease can often lead to full retinal detachment and blindness and result in litigation.

The recurring fact patterns in ROP cases are infants not referred by the neonatologist for an ophthalmologic exam-ination and infants lost to follow-up after initial discharge from a level III NICU for various reasons. These reasons often involve poor communication among providers and poor coordination of follow-up eye care. The parents will often claim they were not told of the importance of timely return visits for ophthalmologic examinations.(42)

Many ROP verdicts and settlements are greater than $1 million, and some occasionally much higher, includ-ing one of $15 million involving twins in 2001, one of $20 million in 2006 (that sent shock waves nationwide through pediatric hospitals and other hospitals with level



III NICUs where infants susceptible to ROP are treated) and one of $38 million in 2008 involving twins.(43)

ROP litigation has occurred with enough frequency and with enough highly publicized large verdicts and settle-ments that it has created problems in the healthcare deliv-ery system in the United States. Ophthalmologists are avoiding treating these patients due to fear of becoming named as a defendant in ROP malpractice litigation.(44)

Risk management and patient safety strategies for reduc-ing ROP risk include the development of a formalized tracking system with responsibilities for appropriate patient care follow up assigned and agreed upon by the healthcare team, along with documentation of discharge instructions and consent to treatment. In the author’s experience, and as suggested in at least one journal arti-cle, many hospitals have designated an ROP coordinator, often a nurse, charged with this responsibility, although this is only one approach to addressing the potential for ROP patients to “fall through the cracks.(45)

The best publication on risk management and patient safety for ROP is “Retinopathy of Prematurity: Creating a Safety Net,” written by Anne Menke, RN, PhD, the risk manager for OMIC, and available on the OMIC web site. This document provides protocols for promoting patient safety and risk management for ROP care in the hospital and for outpatient ROP care.(46)

KernicterusKernicterus cases can arise from neonates treated in any newborn nursery, not just NICUs. All neonates, even full-term, seemingly healthy ones at birth, are at risk for developing elevated bilirubin levels, which undetected and/or untreated can become extreme hyperbilirubinemia and result in kernicterus, a “rare but highly preventable condition” that manifests itself in profound permanent neurological impairment.(47)

Kernicterus is a devastating disorder that can result in lifelong disability or death of a child. The magnitude of this problem has been recognized by the National Quality Foundation (NQF), the American Academy of Pediatrics (AAP), and the Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission issued Sentinel Event Alerts after treatment guidelines had been created by AAP.

Over the first decade of the 21st century, there have been very large malpractice verdicts and settlements involving kernicterus (see Exhibit 1). These cases often are settled due to poor fact patterns and the potential for high jury verdicts.

Recent articles in the pediatric medical literature sug-gest that at least some of these cases may be successfully defended on a causation basis if there is compliance with current screening and treatment guidelines.(48) There is thus some question as to whether kernicterus should have been deemed a “never event” by the NQF. The implica-tion by the NQF was that if elevated bilirubin levels were

monitored appropriately and there was timely intervention (primarily phototherapy and, for severe cases, exchange transfusions), kernicterus could be eliminated. Because of recent articles, the current state of clinical knowledge regarding the kernicterus problem is more muddled.(49)

Risk management techniques for preventing kernicterus involve early diagnosis and prompt intervention and proper parent instructions. The AAP has toolkits available at http://practice.aap.org/content.aspx?aid=2577 for hospi-tals and physicians’ offices that include discharge readiness checklists, follow-up letters, inventories, assessments, and documentation tools and parent handouts. Compliance with the AAP Guideline (most current version as of this publication is the 2004 Guideline) is essential to establish practice within the current standard of care, although recent findings suggest that not all cases can be prevented.(50)

Pediatrics: Children’s hospital claims

Zurich Insurance Company publishes a closed medical mal-practice claim study annually. The study from 2010 looked at Zurich’s experience from 1997 through 2007 and con-cluded that, in comparison to other types of acute care and other facilities, “Children’s hospitals continue to have the highest severity over time. …”(51) (see Exhibit 2).

Pediatrics: Physician claims

The PIAA has been tracking physician closed claims in a cumulative database submitted by member companies since 1985. It is the most credible source for information concerning medical professional liability trends involving physicians. Claims against pediatricians are more expen-sive to resolve than almost all specialties, exceeded only by neurosurgery, neurology, obstetric and gynecologic sur-gery, and radiation therapy (see Exhibit 3).

Pediatrics was ranked tenth among the 28 specialties fol-lowed by the PIAA from 1985 to 2009 regarding the number of claims presented, but ranks fifth in highest average indemnity paid. While the percentage of paid claims to closed was lower than that for all other 28 specialties combined (27.9% versus 29.05%), the aver-age indemnity for pediatrics is significantly higher than the overall average for all specialties ($271,784 versus $212,722). However, there has been improvement in the average indemnity paid in pediatric claims when compar-ing the years 2000–2004 versus 2005–2009 ($474,401 versus $384,504). Pediatrics ranks fifth among all special-ties for the highest average indemnity.(52)

According to the PIAA, the five most prevalent conditions in claims closed against pediatricians in the cumulative study involved the brain-damaged infant, meningitis, children seen for routine health checks, newborn respiratory prob-lems, and pneumonia (see Exhibit 4). Meningitis was not only the second most prevalent condition, but also had the highest average indemnity at $444,488, barely surpassing claims involving a brain-damaged infant at $443,804.(53)



Exhibit 2: Claims Severity by Facilities Type

0

100,000

200,000

300,000

400,000

500,000

600,000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Acute Care Children Hospitals Outpatient Facilities Teaching Hospitals All Others

Source: Zurich Insurance Company, 2010.(51)

Exhibit 3:Top 10 Physician Specialties

PIAA Comparative Claim Payment Analysis

Claims Closed Between 1985 and 2009

Patient Condition ClosedClaims

% Paid to Closed

TotalIndemnity

Average Indemnity

Neurosurgery 5,794 28.41 $532,031,130 $323,227

Neurology––nonsurgical 3,956 21.94 $279,287,658 $321,760

Radiation therapy 2,409 28.44 $202,384,071 $295,451

Obstetric and gynecologic surgery 33,510 35.12 $3,372,306,313 $286,566

Pediatrics 7,186 27.90 $544,926,823 $271,784

Pathology 1,732 28.52 $124,101,295 $251,217

Cardiovascular diseases––nonsurgical 4,735 18.50 $218,678,876 $249,633

Anesthesiology 9,536 32.03 $700,392,192 $229,336

Cardiovascular and thoracic surgery 7,498 23.55 $396,988,303 $224,795

Gastroenterology 2,676 18.54 $109,659,521 $221,088

Totals for Top 10: 79,032 26.30 $6,480,756,182 $267,486

Totals for All Specialties: 247,073 29.47 $15,491,291,841 $212,722

Source: PIAA, 2010.



Exhibit 4:Pediatrics

Claims by 10 Most Prevalent Patient Conditions

Cumulative Analysis: January 1, 1985–December 31, 2009Patient Condition Closed Claims % Paid to Closed Total Indemnity Average Indemnity

Brain-damaged infant 573 28.45 $72,339,971 $443,804Meningitis 329 43.77 $64,006,228 $444,488Routine infant or child health check 201 21.39 $8,442,909 $196,347Respiratory problems in the newborn 180 17.22 $8,897,603 $287,019Pneumonia 147 21.09 $7,925,454 $255,660Appendicitis 145 32.41 $6,605,050 $140,533Specified nonteratogenic anomalies 126 42.06 $10,108,836 $190,733Premature infant 111 16.22 $4,270,368 $237,243Congenital anomaly of genital organs 83 25.30 $4,791,249 $228,155Birth 81 16.05 $3,875,480 $298,114Totals for Top 10: 1,976 28.54 $191,263,148 $339,119Source: PIAA, 2010.(52)


Claims by 10 Most Prevalent Medical Misadventures

Cumulative Analysis: January 1, 1985–December 31, 2009Closed Claims

% Paid to Closed

Total Indemnity

Average IndemnityMedical Misadventure

Errors in diagnosis 2,328 34.88 $226,917,718 $279,455No medical misadventure 1,545 6.54 $34,325,159 $339,853Improper performance 926 28.62 $57,464,109 $216,846Failure to supervise or monitor case 657 35.31 $75,115,769 $323,775Medication errors 338 30.47 $18,388,988 $178,534Failure/delay in referral or consultation 217 43.32 $24,439,234 $259,992Not performed 198 42.93 $18,413,992 $216,635Failure to recognize a complication of treatment 187 29.95 $13,101,517 $233,956Delay in performance 180 39.44 $24,721,067 $348,184Performed when not indicated or contraindicated 110 24.55 $4,949,871 $183,329Totals for Top 10: 6,686 27.61 $497,837,424 $269,684Source: PIAA, 2010.(52)

In the category of medical misadventures reported in the specialty of pediatrics, the most prevalent problem was diagnostic error, reported to the PIAA as the foremost issue in 32.4% of all claims reported in the cumulative study (see Exhibit 5). The five most prevalent conditions resulting in diagnostic error claims included meningitis (with more than half resulting in indemnity payments), appendicitis, congenital anomalies, pneumonia, and the brain-damaged infant(54) (see Exhibit 6).

Hospital departmental quality initiatives can use the PIAA data as a filter through which to examine how various conditions and diseases are treated. For exam-ple, the American Academy of Pediatrics publishes treatment guidelines on appendicitis. It would be instructive for quality purposes to know how children who present with abdominal pain are treated in physi-cian offices, clinics, urgent care centers, or emergency departments.



Risk management pearls in pediatrics

After 10 years as risk manager and in-house counsel at two major pediatric hospitals, and considerable time and effort spent advising clients and researching and writ-ing on pediatric topics over more than 30 years, one can impart a number of practical suggestions for considera-tion in formulating risk management and patient safety strategies.

Staff trainingFor community and rural hospitals treating children in emergency departments and as inpatients, the issue of staff training is vital. This includes physicians, nurses, nurse practitioners, physicians’ assistants, and any others providing hands-on care. The biggest challenge is often the fluctuation in the pediatric census. Caregivers may not see children in sufficient volume to develop these specific skills.

Training and education programs that will further enhance skills in treating children of all ages help man-age risk. Patient simulation labs may greatly assist skills. Patient care protocols, whenever applicable, should be current with the pediatric literature or emergency medi-cine literature, for example.

Pediatric equipmentIn any setting location where there is the possibility of treating a child on an emergency basis, resuscitation equip-ment and supplies should be maintained in all the appro-priate sizes. The American Academy of Pediatrics publishes a list of equipment essential for pediatric care that can serve as a useful guideline for community hospitals.(55)

Environment-of-care risksToddlers are particularly susceptible to the hazards of medical settings. They can reach into open waste baskets.


Claims by Medical Misadventure and Procedure/Condition

Cumulative Analysis: January 1, 1985–December 31, 2009Errors in DiagnosisCondition Closed

Claims% Paid to

ClosedTotal

IndemnityAverage

IndemnityMeningitis 182 51.65 $41,212,211 $438,428Appendicitis 102 37.25 $6,118,551 $161,015Specified nonteratogenic anomalies 76 50.00 $7,512,884 $197,707Pneumonia 62 19.35 $4,859,500 $404,958Brain-damaged infant 59 38.98 $8,387,677 $364,682Totals for Top 5: 481 42.62 $68,090,823 $332,150Source: PIAA, 2010.(52)

They can fall off examination tables or climb out of cribs. Electrical outlets and equipment are a hazard. Supply carts may prove to be tempting. Periodic surveys of pedi-atric patient care areas for these risks and others promote patient safety.

Parent instructionsPrinted and verbal instructions (in the parent’s native language, if possible) can help avoid claims for scenarios where parents must observe the child for any postdis-charge symptoms so long as there is adequate documen-tation of same. It is important for these instructions to communicate the urgency of timely follow-up care as with jaundice or retinopathy of prematurity. Information sheets about a disease or condition can also reduce or eliminate unrealistic parental expectations, thereby preventing a claim.

Pediatric risk management resourcesThere is a wealth of information available from many sources on how to manage pediatric risk. These include the Emergency Care Research Institute (ECRI), the Agency for Healthcare Research and Quality (AHRQ), the PIAA, and the American Academy of Pediatrics, among others.

CONCLUSION

Pediatrics represents a unique risk management and patient safety challenge. Pediatrics is not often thought of as a traditional “high-risk” area, especially in acute care facilities, yet children are among the most vulnerable patients to catastrophic injuries. Claims involving severely injured children are very expensive to resolve. Injuring children creates financial risk and reputational risk. Risk management and patient safety programs should always give pediatric care high priority by analyzing internal event and claims experience along with knowledge of national pediatric claim trends, and by proactively



developing and implementing tools that will help prevent these types of injuries from occurring in the first place.

REFERENCES

1. Federal Interagency Forum on Child and Family Statistics. America’s children: Key national indicators of well-being, 2010. Available at: www.childstats.gov/americaschildren/demo.asp. Accessed July 1, 2010.

2. Ibid.

3. Landau E. Children’s quality of life declining. Available at: www.CNN.com/2010/HEALTH/06/08/children.wellbeing/index.htmil?hpt=Sbin. Accessed July 1, 2010.

4. Federal Interagency Forum on Child and Family Statistics. America’s children: Key national indicators of well-being, 2009. Available at: www.childstats.gov/americaschildren/demo.asp. Accessed July 1, 2010.

5. Ibid.

6. Szabo L. More kids have chronic diseases. USA Today. February 17, 2010;11B.

7. Ibid.

8. Wise P. The future pediatrician: The challenge of chronic illness. J Pediatr. 2007;151(5 Suppl):S6–S10.

9. Landro L. For severely ill children, a dearth of doc-tors. Wall Street Journal. January 12, 2010;D3.

10. Burke R, et al. Impact of children with medically complex conditions. Pediatrics. 2010;126(4):789–790.

11. Woods DM, et al. Child-specific risk factors and patient safety. J Patient Saf. 2005;1(1):17–22.

12. Woods DM, et al. Adverse events and pre-ventable adverse events in children. Pediatrics. 2005;115(1):155–160.

13. Slonim AD, LaFleur BJ, Ahmed W, et al. Hospital-reported medical errors in children. Pediatrics. 2003;111(3):617–621.

14. US Pharmacopeia. Press release, December 4, 2002.

15. Woods DM, et al. Adverse events and pre-ventable adverse events in children. Pediatrics. 2005;115(1):158.

16. Davies T. Fatal Drug Mix-Up Exposes Hospital Flaws. The Washington Post. September 22, 2006. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2006/09/22/AR2006092200815.html?referrer=delicious. Accessed September 21, 2011.

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18. Author unknown. Ohio medical professional liabil-ity closed claim report, February 2011. Available at: www.insurance.ohio.gov.

19. Author’s note: Using Google or other search engines to perform searches with the key words kernicterus and malpractice will result in a lengthy listing of a number of plaintiff ’s law firm sites, such as “New Jersey Jaundice Lawyers.”

20. Physician Insurers Association of America (PIAA). Risk management review. Rockville, Maryland; 2009.

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25. Physician Insurers Association of America (PIAA). Meningitis claims study. Rockville, Maryland; 2000.

26. Selbst SM, et al. Epidemiology and etiology of mal-practice lawsuits involving children in US emergency departments and urgent care centers. Pediatr Emerg Care. 2005;21(3):165–169.

27. Ibid.

28. Ibid.

29. Ibid.

30. Millar AJ, et al. Malrotation and volvulus in infancy and childhood. Semin Pediatr Surg. 2003;12:229–236.

31. Stedman’s Medical Dictionary, 27th ed. Baltimore, MD; 2000.

32. Lampl B, et al. Malrotation and midgut volvulus: A historical review and current controversies in diagno-sis and management. Pediatr Radiol. 2009;39:359–366.



33. Ibid., 365.

34. Klaus M, Fanaroff A. Care of the High-Risk Neonate. 4th ed. Philadelphia, PA: WB Saunders Company; 1993.

35. Rudolph C, et al, Rudolph’s Pediatrics. 21st ed. New York: McGraw-Hill; 2003:203.

36. Lampl, Malrotation and midgut volvulus: 363.

37. Ibid.

38. Behrman R, Kliegman R, Jenson H. Nelson Textbook of Pediatrics. 17th ed. New York: WB Saunders; 2003.

39. Slovis TL, Strouse P. Malrotation: Some answers but more questions. Pediatr Radiol (editorial). 2009;39:315–316.

40. Ibid., 316.

41. Sullivan D. Pediatric abdominal emergencies. Available at: www.thesullivangroup.com. Accessed July 2, 2010.

42. Reynolds J. Malpractice and the quality of care in retinopathy of prematurity (an American Ophthalmological Society Thesis). Trans Am Ophthalmol Soc. 2007;105:461–480.

43. Greve P. ROP: Viewing the risk. Willis Health Trek. 2009;Fall:1–8.

44. Bregel E. Litigation fears halt eye checks for infants. Chattanooga Times, September 6, 2008. Available at: ww.timesfreepress.com. Accessed September 9, 2008.

45. Scott C, et al. Keeping a watchful eye on retinopa-thy of prematurity. Neonatal Netw. 2008;27(5):355–357.

46. Menke A. Retinopathy of prematurity: Creating a safety net. www.omic.com.

47. Sentinel Event Alert. Revised guidance to help prevent kernicterus. JCAHO, Issue 31, August 31, 2004.

48. Bezaire J, Greve P. Kernicterus risk in 2010. Willis Health Trek. June 2010;1–8.

49. Ibid., 6.

50. Ibid., 5.

51. Author unknown. Annual benchmarking report on claims trends in the healthcare industry. Perspectives (Zurich Insurance Company). 2010;16(3):2–10.

52. Physician Insurers Association of America (PIAA). Risk management review. Rockville, Maryland; 2010.

53. Ibid., vii and Exhibit 6.

54. Ibid., vi.

55. Sigrest T, Committee on Hospital Care. Facilities and equipment for the care of pediatric patients in a com-munity hospital. Pediatrics. 2003;111(5):1120–1122. Reaffirmed September 1, 2007.

ABOUT THE AUTHOR

Paul Greve, JD, RPLU, DFASHRM, is currently execu-tive vice president/senior consultant in the Willis Health Care Practice. Paul held risk management and legal coun-sel positions in major teaching hospitals in Ohio, including two pediatric hospitals: Columbus (Nationwide) Children’s Hospital, and Rainbow Babies and Children’s Hospital in Cleveland. He has worked for two malpractice carriers, including the Medical Protective Company. Paul has been a board member of both the Ohio and Indiana Societies for Healthcare Risk Management and is the past president of the Ohio Society for Healthcare Risk Management. He is a Distinguished Fellow of ASHRM. He has published numerous articles and textbook chapters on risk manage-ment and medical-legal subjects, including many on pedi-atric risk.


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Pediatrics: A unique and volatile risk