Misdiagnoses of Appendicitis TABLE 5 Common Gastroenteritis; upper respiratory illness; otitis; sinusitis; pelvic inflammatory disease Pneumonia; sepsis; urinary tract infection; encephalitis/ meningitis/encephalopathy; febrile seizure; blunt abdominal trauma Less common
Adapted from Becker T, Kharbanda A, Bachur R. Acad Emerg Med. 2007;14(2):124–129 and Reynolds SL. Pediatr Emerg Care. 1993;9(1):1–3.
Conditions Associated With Nonteratogenic Anomalies
Condition Median Indemnity, $
Spine (eg, spina bifida occulta)
Metatarsus varus/valgus/bowing/genu recurvatum
45 000–400 000
symptoms and signs. To assist with this high index of suspicion, use acceptable pediatric telephone triage and advice protocols when physicians are not providing tele- phone triage. Periodically, monitor triage and advise staff to ensure that they are adhering to your protocols and that documentation is adequate. Be sure that non- clinical staff is not providing clinical advice to parents. Be aware of “red flags” such as “a strange look” or “walking funny” or the development of progressive symptoms.
Twelve percent of the PIAA meningitis claims in- volved problems with the medical chart. These problems included failure to document standards of practice, fail- ure to record pertinent negative findings relevant to the diagnosis, failure to record interactions with the patient, and failure to record referrals to other physicians. Alter- ations in the chart were also noted.
Communication issues were also cited as an associ- ated problem that allegedly contributed to the delay in diagnosis because of poor communication between pro- viders, failure to inform of critical test results, failure to provide the consultant with a complete account of med- ical findings to date, and failure to provide the patient with clear follow-up instructions.
APPENDICITIS From a medicolegal perspective, appendicitis presents a particularly difficult diagnostic problem, especially in young children. The perforation rate is inversely related to the age of the patient, making diagnosis in the younger patient critical.8 Missed diagnoses have been reported in up to 27% of cases.9–12 Atypical symptoms and signs are not uncommon and often underlie the misdiagnosis.9–12 Atypical positive symptoms include di- arrhea, vomiting before pain, upper respiratory symp- toms, minimal right lower quadrant pain, and constipa- tion. Atypical negative symptoms include lack of fever, absence of rebound or guarding, normal appetite, and normal (or increased) bowel sounds. Some patients are seen twice before the correct diagnosis is made.10,11 Fe- male adolescents are frequently misdiagnosed, with symptoms attributed to pelvic inflammatory disease or urinary tract infections.11
Common misdiagnoses are listed in Table 5. PIAA claims with failure to diagnose as the cause of action paid out 36.7% of the time for an average indemnity pay- ment of $131 842.6
NONTERATOGENIC ANOMALIES/CONGENITAL ANOMALIES OF THE GENITAL ORGANS Overall, the average indemnity payout for specified non- teratogenic anomalies was $197 707. Claims for nonter-
Conditions Associated With Genital Anomalies Condition Median Indemnity, $
Undescended/retractile testicle (60%) Hypospadias/epispadias (20%) Anomalies of uterus/other female organs
95 000–250 000 63 000 120 000
atogenic anomalies are usually a result of a failure to diagnose (50% of claims) rather than failure to refer (3% of claims). Nevertheless, subspecialty referral may be indicated, because these conditions may be a compo- nent of an underlying genetic syndrome.
Developmental dysplasia of the hip (DDH) previously represented nearly three quarters of the claims in the PIAA database.6 However, this frequency has been de- creasing over the years, presumably because of better awareness of the condition with earlier and better diag- nosis, particularly since the advent of ultrasound tech- nology. DDH is an example of a condition for which identification of certain risk factors can translate into effective risk management. Risk factors for DDH are present in up to 25% of cases and may include female gender, breech presentation, cesarean section, oligohy- dramnios, family history of DDH, being firstborn, hered- ity (eg, Italian, Native American, Japanese), associated neuromuscular conditions such as torticollis and meta- tarsus adductus, and possibly swaddling.13,14 However, absence of risk factors should not reassure a practitioner that DDH is not present.15 The average indemnity paid for a misdiagnosis of unilateral and bilateral DDH was $100 000 and $200 000, respectively.6
Other common causes of action for nonteratogenic anomalies and congenital anomalies of the genital or- gans and median indemnity amounts are listed in Tables 6 and 7.
PNEUMONIA Compared with other diagnoses, fewer closed claims resulted in a payout for failure to diagnose pneumonia. Nevertheless, this diagnosis resulted in the second high- est average indemnity paid out since 2001.6 There are few specific data that permit specific recommendations for risk management for this condition. Pneumonia is typically divided into 2 clinical types: community-ac- quired pneumonia (CAP) and nosocomial pneumonia. Although there are several clinical guidelines for man- aging CAP in adults, guidelines for CAP in children have not been universally accepted. Thus, there are variations relating to diagnosis of children with this condition. The average indemnity for errors in diagnosis relating to pneumonia was $396 318.
McABEE et al