BRAIN-DAMAGED INFANTS Virtually any medical scenario in which an infant or child has sustained brain damage is highly likely to result in a lawsuit. These claims tend to relate to newborns. Examples include head injury from a fall after an abrupt vaginal delivery,16 profound developmental delay from inadequate hydration of a dehydrated newborn,17 and developmental delay and cerebral palsy secondary to failure to timely diagnose and treat hypoglycemia.18 Typ- ical reasons for initiating a lawsuit for a neonatal brain- injury claim have been reported to include concerns for a medical “cover-up,” the parents’ need for medical in- formation about their infant, the need for financial sup- port to help care for the infant over a lifetime for a child whose parents do not recognize a future, dissatisfaction about communication between physicians and parents, and desire for revenge.19 In 70% of cases, the parent expressed dissatisfaction that caretakers did not warn him or her about the possibility of long-term neurode- velopmental problems.19 The latter point suggests that parents do not like “surprises” when they are told later that their child is developmentally delayed because of events during the newborn period.
Average indemnity payments for a brain-damaged infant are among the highest for pediatric claims (aver- age indemnity: $440 379 [for all claims] and $335 804 [for claims relating to diagnostic error]).
MEDICATION ERRORS Issues related to medication are relevant to all medical diagnoses and account for 5% of malpractice cases involving children.6 A review of the PIAA data reveals valuable information about malpractice claims relating to medications.
In pediatrics, it is not surprising that allergy and re- spiratory medications, 2 of the more commonly pre- scribed classes of drugs, are frequently the basis for mal- practice actions. The average indemnity paid for these classes of drugs was $325 676 for asthma medications and $180 140 for bronchitis medications. However, a third class of drugs commonly associated with malprac- tice claims involves the anticonvulsant drugs, with an average indemnity paid of $97 500. Studies have raised concerns about pediatricians’ knowledge about the pharmacokinetics of some anticonvulsant medications.20
Errors arise in 1 of 4 ways: ordering (56% of errors); administration (ie, wrong dose, drug, timing, or tech- nique) (34% of errors); transcription (6% of errors); and dispensing (4% of errors).21
PIAA data show that 14% of medication claims are allergy related. These claims fall under 3 categories: failed to ask about drug allergy; asked about and previ- ously documented drug allergies but failed to read the medical chart; and failed to re-ask about recent devel- opment of drug allergy. Physician-related mistakes oc- curred in 69%, nurse-related mistakes in 13%, and pharmacy-related mistakes in 8% of the claims. Thirty- seven percent of cases involved an incorrect dosage, an inappropriate drug, or failure to monitor adverse effects.
Practitioners should inquire about drug allergies ev- ery time a prescription is written. Practitioners should
also consider prescribing anticonvulsant drugs in close consultation with the appropriate specialists. For pediat- ric inpatients, computerized prescriber order entry sys- tems have been effective in reducing the incidence of adverse drug events.22
PEDIATRICIANS PRACTICING IN EMERGENCY SETTINGS Pediatricians practicing in emergency settings must be especially cognizant of the common causes of malprac- tice suits. An analysis of the PIAA database regarding pediatric lawsuits arising in an emergency department setting from 1985 to 2000 noted that common causes of malpractice suits involved meningitis, neurologically im- paired newborns, and pneumonia in suits involving chil- dren 2 years old; fracture, meningitis, and appendicitis in lawsuits involving children from 3 to 11 years old; and fractures, appendicitis, and testicular torsion in lawsuits involving children from 12 to 17 years old.23 Cases in which death occurred often related to meningitis and pneumonia.
GENERAL RISK-MANAGEMENT TECHNIQUES Some generalized risk-management techniques are use- ful regardless of the medical diagnosis. These techniques include:
Document all pertinent positive and negative clinical findings. For example, meningeal signs may be lack- ing in a patient with meningitis, and the proper diagnosis may be missed. However, the physician who has documented the absence of meningeal signs has provided some evidence that he or she considered the possibility of this condition and has properly evaluated the child.
Document carefully. The medical chart should con- tain the information that the physician would want present if a claim were to be made in the future. Entries should be clear, complete, and free of flip- pant, critical, or other inappropriate comments. Whenever writing on a medical chart, assume that “Dear Mr/Ms Attorney” is written at the top. One day this is who may be reading it.
Although there are differences of opinion about how much to write in a medical chart, quality is always preferred over quantity.
When appropriate, do not underestimate the impor- tance of referring to specialists.
If a patient has identified risk factors for a specific condition, visibly and clearly “red flag” the front of the chart as a reminder to check for the condition at each visit. This is especially important for conditions such as DDH, for which the age of onset and diag- nosis varies widely.
Communication and use of terminology is critical. Numerous studies have demonstrated that poor communication between physicians and parents/pa- tients is the catalyst for most medical malpractice lawsuits. Good communication involves the use of layman’s terms and the avoidance of medical jargon.
PEDIATRICS Volume 122, Number 6, December 2008 Downloaded from www.pediatrics.org by on January 13, 2009