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Administration/Practice Management, Emergency Medicine, Risk Management, News
Articles, Pediatricians and the Law
Know where to turn when risky situations arise
by Karen A. Santucci M.D., FAAP
You are working in a busy children's emergency department (ED) when a 16-year-old girl with right lower
quadrant pain comes in. The differential is fairly broad, but based on the severity of the pain, you order a
transabdominal ultrasound hoping to visualize the appendix as well as her right ovary.
The appendix is normal in size, but there is no documented flow to the ovary. You explain the need for
emergency surgery, but the teen says she feels better and refuses intervention as does her mother who is her
legal guardian. They leave the ED "against medical advice" despite your pleading with them to reconsider. You
are left with a sick feeling in your stomach and wonder how you might be able to obtain guidance to protect your
patient's safety and legal advice to protect your organization and yourself.
In scenarios like this, assistance from your hospital's risk management or legal department may be available but
challenging to access after hours. Familiarizing yourself with how to reach on-call administrators and off-shift
executives will reduce your stress level. Not every pediatrician, however, works in a setting with such
professionals.
Knowing how to obtain risk management and patient safety guidance from resources with a national scope,
regional presence and data-driven insights is essential.
Sources of information
Medical liability insurance companies provide practical risk management resources to address clinical event
trends as well as patient outcome information. They are well-positioned to offer strategies to minimize risk and
support safer care. They also can provide early intervention and perform site/hospital/practice surveys,
customize risk management strategies, and provide bulletins, online webinars and seminars covering specialtyspecific risks.
The Agency for Healthcare Research and Quality (AHRQ) (www.ahrq.gov/) uses a system of quality indicators
to determine the standards of quality health care and if a particular provider is meeting those standards. The
AHRQ publishes performance results in an annual report and translates its research into actionable reports,
toolkits and other implementation resources.
The indicators are divided into four subcategories that monitor a different aspect of health care quality:
●
Prevention Quality Indicators (PQI) are used to identify hospital admissions that might have been
avoided through a higher quality of outpatient care. This will be relevant primarily when there is a
return visit for a patient. Its set of measures combined with hospital inpatient discharge data are used
to identify conditions for which good outpatient care can potentially prevent the need for hospitalization
or early interventions to prevent complications or more severe disease. These are population-based
and adjusted for covariates.
●
Inpatient Quality Indicators (IQI) provide a perspective on hospital quality of care using hospital
administrative data. These indicators include inpatient mortality rates for certain procedures and
medical conditions. They may identify potential over-, under- or misuse of procedures. Numbers
studied reflect patient mortality rates in a given hospital caused by lack of care or lack of a surgical
intervention.
Copyright © 2016 American Academy of Pediatrics
Administration/Practice Management, Emergency Medicine, Risk Management, News
Articles, Pediatricians and the Law
●
Patient Safety Indicators (PSI) deal with hospital mortalities related to avoidable complications like
those caused by expired medications or outdated hospital machinery. These indicators show potential
in-hospital complications and adverse events following surgeries, procedures and childbirth. The PSI
are based on a comprehensive literature review analysis of International Classification of Diseases
codes, review by a clinical panel, and risk adjustment and empirical analyses.
●
Pediatric Quality Indicators (PDI) screen for problems pediatric patients experience from exposure to
the health care system. They focus on problems amenable to prevention by adjustments at the system
or provider level.
Closer to home, health care managers identify and evaluate risks to reduce injury to patients, staff members and
visitors within an organization. Risk managers work to prevent an incident or to minimize the damages after an
event. For example, the scenario above poses many risks, most importantly harm to the minor patient. Other
risks include diagnostic, surgical or medication errors; hazardous conditions; potential patient privacy breaches;
and an increase in liability for the physician and hospital.
Risk managers review the situation's facts and offer solutions to the immediate issue at hand. Based on these
experiences, risk managers plan for future issues or emergencies, often developing or revising policies and
procedures. They also can recommend and conduct additional staff training to prevent errors.
Risk management pointers
Scenarios like the one presented often occur after normal working hours. Following are actions you can take to
reduce your medical liability risk and protect your patient in a similar situation:
●
Stay calm and clearly convey risks and benefits to the patient and family.
●
Contact the patient's pediatrician, who usually has a longstanding relationship with the teen and family.
●
Reach out to an adolescent gynecologist or surgeon who can reinforce your concerns with the patient
and parent.
Carefully chart all conversations.
After a flurry of activity, several phone calls and an impeccable note in the chart documenting every
conversation, the family returned to the ED and the teen had a successful operative procedure that saved her
ovary.
●
Dr. Santucci is a member of the AAP Committee on Medical Liability and Risk Management.
Resources
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Medicolegal Issues in Pediatrics, 7th edition describes key legal issues facing pediatricians and pediatric
subspecialists and provides detailed analysis of common pediatric malpractice claims.
●
The monthly Pediatricians and the Law column in AAP News analyzes emerging medicolegal issues and
provides practical risk management strategies to address them in a variety of health care settings.
Copyright © 2016 American Academy of Pediatrics