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Pediatric Risk Strategies

An analysis of CAP-MPT's pediatric claims identified the most common problem as the failure to diagnose a physical condition, most often, meningitis or sepsis. Surprisingly, most errors were found to be rooted in simple failures of history taking, physical examination and/or communication. Thus, the following Risk Management considerations, basic to successful practice, are presented. It is our desire that they will assist our physician members in their medical management of infants, children and adolescents.

Listen to parents

• They know their child better than you do.
• Consider it a red flag when the parents say, "My child has never acted like this (or been this sick) before."

Avoid the first diagnosis mind-set

• Consider other diagnoses. Children with meningitis or sepsis often have red eardrums.
• Be especially vigilant when you are tired and/or stressed.
• Recognize your subconscious bias to deny that the child has a serious disease.

Before approaching the child, observe for signs of distress and activity level.

• Document all vital signs and activity level.
• Tachypnea is an important sign of pneumonia and asthma.
• Remember, children with severe asthma may not wheeze.
• Remember, children with appendicitis want to stay still.

Involve the parents in decisions about tests and follow-up.

• Share the responsibility for diagnosis and management with the parents.
• Give specific directions about what to do if the child does not improve and document.

Document, document, document.

• Document "non-toxic" activity, alertness, eye tracking, neck suppleness, fontanelle.
• Document why LP, CBC, blood culture or chest film not warranted.
• Avoid degrading or humorous notes of any kind.

Always think meningitis, especially in sick infants and young children.

Special thanks to Marlene Coleman, M.D., for her contributions to this project.