Skip to Main Content
Skip Nav Destination

Know where to turn when risky situations arise :

November 30, 2016

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 specialty-specific risks.

The Agency for Healthcare Research and Quality (AHRQ) ( 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.
  • 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.

Close Modal

or Create an Account

Close Modal
Close Modal