T he laws of all jurisdictions in the United States authorize the provision of chiropractic care to patients of all ages. No state places any limitations or conditions on chiropractic care based on age. Doctors of chiropractic, indeed, provide clinically effective, safe and appropriate care to hundreds of thousands of children of all ages each year in the United States. The provision of health care services to children by any health care professional does, however, raise the risk management bar for a number of significant reasons. Doctors of chiropractic need to be constantly aware of the need to handle all cases involving children with exceptional attention to detail in analysis, communication with parents or guardians and, above all, in documentation.
How Real is the Chiropractic Pediatric Malpractice Risk? The exceptional safety record of chiropractic across all categories of patients extends, thankfully, to the child patient population as well. While chiropractic pediatric malpractice claims are rare, especially by comparison to medicine, the reality of exposure should not be minimized. This is especially true given the highly emotional nature of issues related to children and the damaging nature of any implication that a health care professional may be at fault.
There are obvious situations where red flags present themselves, especially in situations where emergency or trauma-related care is sought, where parents are being less than forthcoming as to the exact nature of the child’s condition or where medication or substance-related issues may be present. These situations require careful, cool and exact thinking on the provider’s part and will frequently call for a widening of the pool of professionals involved in such cases by a prompt referral and direct follow-up communication with one or more other classes of providers. The record shows that there is a direct correlation between the sense of crisis and emergency on the part of the parent of a sick or injured child and the possibility of claims of malpractice, regardless of the real merits of such claims.
Exact current data on pediatric malpractice across all health professions is limited, but a detailed study of 2004-2005 data from the federal National Practitioner Data Bank showed that 14% of payments made during that two-year period involved pediatric cases, with $1.73 billion paid in settlement of malpractice cases involving children. That same study revealed that “failure to diagnose” was the basis of 18% of all pediatric malpractice cases. Delay in diagnosis and “improper performance” were the next two main reasons for pediatric malpractice claims, at 9% each.i
Whatever the statistics, a concentrated program of pediatric malpractice risk reduction is in the best interests of all doctors of chiropractic who have even one child in their practice.
Communication: Communication in cases involving children, especially small children, is inherently complicated by the fact that the ability to communicate on their part is limited. The ability of a child to describe their complaint(s), relate the exact details of an injury or trauma incident, describe what substances they may have consumed or been exposed to, the duration of a problem and other key factors is limited. In the case of infants, it is absent completely. You often must rely on your evaluation of the patient and the narrative of the parent or parents.
Even in the cases where on intake your initial assessment is that a child is an uncomplicated case, take a few extra moments to ask those extra questions of the parent to seek to identify any significant or extraordinary facts involving the child’s history of incidents and injuries, changes in patterns of behavior including eating and sleeping and other variables that may raise questions about the state of the child’s health that might not otherwise be immediately revealed.
Extra care and clarity is also required in your communications back to the patient and/or the patient’s parents or guardians. This is especially the case where a referral to another provider is made or follow-up procedures are indicated. The Institute of Medicine has noted that half of Americans, even among the well educated, do not understand basic health information.ii Other research shows that many Americans lack good reading, listening and concentration skills, especially where unfamiliar health care terms are involved. Some experts have advised that all verbal instructions should be simple, clear, concise, and repeated until the patient/parent acknowledges understanding. Some have even advised that all written material provided to patients should be written at the eighth-grade level. Records of such communications on behalf of child patients must be included in the patient’s clinical record.
A child’s health status and prospects are sensitive and often highly emotional issues with parents. Some added sensitivity and patience may, at times, be required in dealing with pediatric cases. Parents can sometimes feel themselves responsible for a child’s injury or condition, and there may be rare instances where this is the case. Child abuse situations apart, which require the strictest and most immediate implementation of the reporting requirements of your jurisdiction, your help in assessing at-home safety procedures, care patterns and such issues as how a child sleeps or is routinely carried may merit your serious attention and dialogue with parents. Be careful in how you respond to such situations, as you never want to be in a position of being quoted as saying that any activity, care pattern or environmental situation is “OK” when the exact details might be incomplete or the information provided misleading.
Documentation: The clinical record through which all aspects of a pediatric case are documented is, as with all other categories of patients, the practitioner’s first and best line of defense. In cases involving children, there is an added level of documentation required including annotation and inclusion of copies of or details on information provided to parents, answers to questions asked and other issues discussed. Being able to document the information provided parents at the time of care, especially any positive findings, clinically indicated follow-up care needed and/or referral advice can be key elements in defending a malpractice claim.
Expect the Unexpected: Children can be mobile, unpredictable, fearless and not aware of risks and dangers.
It is also essential to document negative findings and the results of any instrumentation or physical tests and observations since failure to diagnose is a reason for malpractice claims. An analysis of pediatric malpractice court cases has shown that the provision of any clinical measurement, diagnostic imaging (which is problematic for most pediatric chiropractic cases on safety grounds) laboratory results or other quantified study or instrumentation finding carries significant weight in defending care decisions and will significantly help in outweighing the opinion of an opposing expert. As well, incomplete, inadequate, un-timely or inappropriate documentation is what allows so many non-meritorious claims to proceed so successfully.
It is important for practitioners to always extend the same security and HIPAA confidentiality procedures to children’s files and to be aware that the statute of limitations and state-established requirements to maintain those files almost always extends to a period of years after the child has reached the age of legal adulthood. It would be time well spent to find out what the specific requirements for record maintenance for child patients are in your jurisdiction.
Referral: Doctors of chiropractic can strengthen their clinical defenses, especially in complex or problematic cases, by referring the parents of a child patient to another professional for evaluation and/or additional care. Where children are involved, the promptness of such referrals and on-going communication and follow-up with both the professional to whom the referral was made and the parents almost always strengthens your defensive position. Where medication errors, unforeseen consequences of medication, substance abuse or infectious diseases are suspected, such referrals become urgent. Nothing in any referral should be means to imply that you are releasing the child patient permanently from chiropractic care and should only imply that the skills of other professionals are in the best clinical interests of the patient at a specific time
Clinic Environment and Physical Safety Issues: Starting with physical layout and patient safety issues, you will want to carefully survey every square foot of your clinic from a child’s eye point of view. You will want to look for loose tiles or carpet, cords and wires that might have found their way into walkways, sharp corners on tables, desks, filing cabinets and any other physical items into which patients might easily bump, trip over or fall on. Also, don't forget to look at anything with which your patients come into contact, including the coffee machine if you have one, making certain that it is up far enough so that it is out of reach of children, and likewise check any water cooler, making sure that it is stable and not easily tipped over. Please don't forget to look at the outside of your clinic, including parking facilities and your doors and sidewalk.
The next category of items and issues you should review relates directly to your professional activities, and starting with the adjusting tables, make sure that all are stable, in good repair and functioning as they were intended to function. Don't minimize the importance of keeping your tables in tip-top shape. Injuries to patients because of faulty equipment are 100 percent preventable, and, especially when heavy, power-driven lift tables are in use, represent an important risk management area.
The wiring of tables is of special concern regarding child safety. In June, 2011, in Minneapolis, Minnesota, an 18-month-old toddler crawled under a chiropractic table to which his mother had been strapped and immobilized and hit the control button, causing the table to lower directly on top of the child. Despite an almost instantaneous response by the clinic staff to the mother’s cry for help, the infant died of his injuries. Sadly, this is not the first incident involving the death of a small child by an electric table on which the switch was activated by a crawling child. Safety switches that cannot be causally or accidentally activated are essential.
There is also a behavioral element to such kinds of risks. Allowing small children to move freely about clinic areas unattended means that unexpected and unintended incidents can and do happen. Policies and staff support that minimize any unsupervised time can certainly help. Be thoughtful and cautious in asking patients not to bring their children with them when they come in for care, as a family-friendly environment is a powerful asset both to the strength of the practice and the healing nature of the clinic’s environment.
Expect the Unexpected: Children can be mobile, unpredictable, fearless and not aware of risks and dangers. It makes sense to do all you and your staff can to make your clinic a safe, welcoming and healing environment for all patients, however small, and the people who bring them in. To be constantly on watch when children are present just makes good sense. To always act at the highest professional standard in patient analysis, care delivery and documentation is your obligation, not just for children, but for all patients.
- Kain, Z.N, MD, MBA, FAAP, Caldwell-Andrews, Allison, A., PdD, (August 1, 2006). What Pediatricians Should Know About Child-Related Malpractice Payments in the United States. Pediatrics, 118(2), 464-468 (doi: 10.1542/peds.2005-3112).
- Institute of Medicine, Committee on Health Literacy (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press..
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