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Medical Diagnoses Commonly Associated With Pediatric Malpractice Lawsuits in the United States Gary ... - page 3 / 7





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Average Indemnity (for All Claims), $

1. Brain-damaged infant 2. Meningitis 3. Routine infant or child health check 4. Respiratory problems in newborns 5. Appendicitis 6. Pneumonia 7. Specified nonteratogenic

440 379 437 423 155 039 270 607 116 285 239 531 186 708

8. Premature birth

250 031

9. Birth

286 407

10. Asthma

193 414


Most Prevalent Conditions Resulting in Malpractice Lawsuits (in Order of Frequency)



Most Prevalent Conditions in Pediatric Malpractice Claims Caused by Error in Diagnosis (1985–2006)


Average Indemnity

(for Diagnostic Errors), $

1. Meningitis

433 464

2. Appendicitis

131 842

3. Specified nonteratogenic anomalies

197 707

4. Pneumonia

396 318

5. Brain-damaged infant

335 804

TABLE 4 Presenting Symptoms in Cases of Meningitis Symptom


Fever Nausea/vomiting Lethargy Headache Influenza symptoms Change in mental status Poor appetite Neck stiffness Surgery Photosensitivity

74 49 32 27 25 12 11 10 6 3

TABLE 3 Initial Diagnoses in Cases of Meningitis Condition


Viral infection/influenza Other Meningitis Ear infection Gastroenteritis Urinary tract infection Postoperative infection Migraine Febrile seizure

35.6 24.9 12.3 12.3 4.1 2.7 2.7 2.7 2.7

that may reduce the potential risk of misdiagnosis and liability risk associated with these conditions will be discussed. It should be noted that although an insurance database relating to medical malpractice may contain a wealth of claims data, it is also likely to be incomplete and even fragmented. Thus, analyzing every question related to clinical care and subsequent malpractice ac- tion may not be possible. Nevertheless, the information provided should be invaluable to the practitioner.

MENINGITIS Meningitis continues to be a major issue among pediatric malpractice allegations, resulting in one of the most expensive medical conditions in regard to average in- demnity costs and average costs to defend. From a mal- practice perspective, the PIAA Meningitis Claims Study noted that meningitis lawsuits are predominately a pe- diatric problem.7 The median age of the patient with a meningitis claim was 2 years, indicating the large num- ber of infants and toddlers involved. Sixty percent of claims involved patients 2 years of age. In 82.6% of meningitis claims that involved patient death, the pa- tient was 1 year of age. The highest average indemnity ($433 464) was paid on behalf of pediatricians who were the most frequently sued physician group for this diag- nosis.6 The high expense of these claims relates to the long life expectancy of a child with neurologic sequelae as well as the higher rate of mortality. Generally, any pediatric malpractice case that involves a death has both a higher incidence and amount of a payout. The most common cause of action in meningitis cases was delay in diagnosis. Relevant to the progression of symptoms is

that the time between first examination and diagnosis was 3 to 24 hours in 43.8%; treatment was sought within 24 hours of symptom onset in 57.5%; and anti- biotics were given within 24 hours of contact in 49.3% of the cases. The initial contact varied (office, 35.6%; emergency department, 30.1%; telephone, 17.8%; hos- pital, 9.6%; urgent care/home visit, 5.5%). The average payout was twice as high when initial contact was with a nurse (12.3% of claims). Also, payout for claims re- sulting from telephone-based care was one third higher than for those resulting from non-telephone–based care. Sixty percent of claims resulting from telephone-based care involved children 2 years of age. Initial diagnoses for meningitis cases are listed in Table 3, and presenting symptoms and their frequency are listed in Table 4. An important statistic for the practitioner is that 25% of children did not present with fever, and the majority of them lacked change in mental status, headache, leth- argy, and neck stiffness. The absence of stiff neck is likely from the lack of meningeal signs associated with the younger age of these patients. Lumbar punctures were not performed in nearly 30% of cases resulting in claims, which probably reflects the lack of suspicion of menin- gitis, especially in infants and toddlers. Yet, of the claims regarding cases in which a spinal tap was not performed in a timely fashion, the average age of the patient was 7 years.

Because typical central nervous system signs and symptoms are frequently absent at presentation, risk management is challenging. There is no such thing as too high of an index of suspicion for meningitis, espe- cially for infants and young toddlers during “flu” season. Because of the increased space that exists between the brain and the inner calvarium in an infant, a great deal of pathology can occur before the onset of neurologic

PEDIATRICS Volume 122, Number 6, December 2008 Downloaded from www.pediatrics.org by on January 13, 2009


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