LOS CABOS, MEXICO—Ten simple practices can significantly reduce the likelihood that a pediatrician will make a mistake and be sued, Ramon W. Johnson, M.D., said at a pediatric conference sponsored by Symposia Medicus.
The conventional wisdom among medicolegal experts is that the emotional cost of a malpractice lawsuit is so profound, even the physician who wins a case actually loses, noted Dr. Johnson, director of pediatric emergency medicine at Mission Hospital Regional Medical Center, Mission Viejo, Calif.
Therefore, it is better to avoid suits. And, one way to avoid suits is to reduce the likelihood of any mishaps or mistakes.
The following are Dr. Johnson's suggestions made for reducing common mistakes:
▸ Stated protocols. Physicians should have a policies and procedures manual in the office that addresses common pediatric issues, such as a triage protocol, a fever protocol, and a sedations protocol.
“Whatever it is that you decide is a situation where you do not want to have any gray zone, put it down in a policies and procedures manual,” Dr. Johnson said.
A manual can come back to haunt you if you somehow deviate from your own stated procedure and a suit arises, but proper documentation explaining why you deviated from that protocol can defend you.
“I do think that for many, many patients, it is better to have a system where everybody is on the same page and knows how to get that child through the system,” Dr. Johnson said.
▸ Use kilograms. Since drug doses are given in mg/kg, using pounds in the chart anywhere is asking for trouble. “Get rid of that pound scale if you have it,” Dr. Johnson said.
▸ Broselow tape. Having a Broselow tape that you can lay down next to a child and get a drug dosage without having to make any mental calculation is crucial anyplace where one might do urgent care. “In the heat of battle, nobody can multiply or divide, even by 10,” he said.
▸ Rectal temperature. Ear and axillary thermometers are notoriously inaccurate in reflecting actual core temperature, and missing a fever could cost millions in a lawsuit.
Therefore, everyone should have electronic thermometers, oral for older children and rectal for younger children. “Anyone who is not using rectal temperatures in children under 2 [years] is not doing the right thing,” Dr. Johnson said.
▸ Urine catheters. Urine collected by a bag is almost always contaminated with skin bacteria. Therefore, if you don't use a catheter to collect urine and it proves to be positive, you can't really be sure, Dr. Johnson said.
Urinary tract infections may be more common than once thought, he noted.
▸ Pulse oximetry. It is impossible to predict mild to moderate hypoxia in a child, and attorneys frequently pounce on whether or not a child had pulse oximetry done, and what the value was because this can be an initial sign that a child really was ill.
“The pulse ox should be the fifth vital sign,” he said.
▸ Decimal points. Zeros should be used before a decimal point, and never after, when recording medication dosages. A dose of 1.0 mg can look like 10 mg when it is handwritten. If everyone in the office knows the standard for writing doses, mistakes are less likely to happen.
▸ Equipment. Get equipment that is properly fitted for children, and make sure your local hospital has such equipment. A well-equipped Broselow bag that is kept handy will help solve this problem.
▸ Drug concentration. Keep only one concentration of the important medications on hand. If there are two concentrations, “I guarantee you that sooner or later someone is going to receive the wrong concentration,” Dr. Johnson said.
▸ Gowns. If there is a major problem in health care, it is the failure to undress the patient, Dr. Johnson said. Regardless of the chief complaint, almost all children should have a brief physical examination during an office visit. At the very least, bruises and other possible signs of physical abuse may be missed.
“As you know, a lot of things hide below the diaper,” he added. “A lot can be learned from looking at the skin, and that goes for any age group.”