A mother brings her 18-month-old son to the office with a scald burn. He is supposed to be given acetaminophen but receives oxycodone instead — a 10-fold opioid overdose.
The mother is informed of what happened. The child is given naloxone, placed on monitors and has labs drawn. The patient, who should have required only wound cleaning, proper bandaging and outpatient follow-up, was transferred by ambulance to a tertiary care hospital for monitoring. Fortunately, he had no long-term consequences.
While the team did not hesitate to tell the mother what happened, open and honest communication about medical errors has not always been the norm.
The updated AAP policy statement Disclosure of Adverse Events in Pediatrics emphasizes that disclosure now is widely regarded as the ethical and appropriate response to medical errors.
Data indicate that patients and families affected by medical errors may be less likely to pursue litigation after open and honest communication, and legal settlement amounts may be lower. Disclosure also can help maintain trust in the health care system. And a culture of open communication can facilitate support and healing for clinicians involved in medical errors.
The policy, from the AAP Committee on Medical Liability and Risk Management and Council on Quality Improvement and Patient Safety, is available at https://doi.org/10.1542/peds.2025-070880 and will be published in the April issue of Pediatrics.
Types of errors, populations most affected
In 1999, the Institute of Medicine issued the report To Err Is Human, which brought to light the frequency of medical errors. Since then, studies have shown that medical errors in the U.S. cause up to 250,000 deaths and cost close to $20 billion annually.
While the magnitude of harm from medical errors in pediatrics is not well-understood, preventable adverse events occur frequently. With most pediatric care occurring in ambulatory settings, significant numbers of errors are related to medications, vaccines, diagnoses, and coordination and transitions of care. Medication errors are estimated to be three times as common in pediatrics as in adult populations.
Since the prior policy statement was published in 2016, research has revealed that children with special health care needs, medical complexity and from historically marginalized populations are more likely than others to experience medical errors.
Data have shown higher rates of adverse events among pediatric patients who are Latino, have public insurance and come from families with limited comfort with English. Rates in these groups may be even higher than estimated due to disproportionate underreporting of errors affecting them.
Initiatives, laws support disclosure
The policy statement encourages involving children and adolescents, including those with chronic illness, in disclosures, and individualizing disclosure. Special considerations may apply to adolescent confidentiality.
National and state initiatives supporting disclosure have increased in recent years, and many institutions, practices and clinicians have become more comfortable with open communication after adverse events.
The Veterans Health Administration was an early leader in disclosure (https://bit.ly/3COJBuQ). In addition, the Communication and Optimal Resolution Program (https://bit.ly/3EBnAA1) was adopted by the U.S. Department of Health and Human Service’s Agency for Healthcare Research and Quality.
A few states, such as Massachusetts and Colorado, have passed laws or implemented programs that encourage prompt and open disclosure and support for health care workers involved in adverse events. A majority of states have laws protecting clinicians’ statements of apology from use in court.
Barriers to disclosure
Shame, fear of professional and legal repercussions, and lack of knowledge or training in best practices continue to hinder disclosure.
Recent efforts by the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges urge training in communication, effective disclosure and identification of system failures to contribute to a culture of safety.
When medical errors occur, clinicians can rely on publicly available tools (https://bit.ly/3Qle1bk) or institutional resources along with guidance from practice leaders, attorneys and risk managers.
The team involved in the administration of oxycodone instead of acetaminophen to the young boy held a debriefing to discuss factors that contributed to the error and ways to prevent such errors in the future. The risk management office was contacted, the event was investigated and changes were implemented to prevent similar errors. Clinicians were offered resources for support, and the family was contacted. All of these steps have been shown to be important to clinicians and families affected by medical errors.
Clinicians and institutions can encourage open communication and a culture of learning from medical errors by focusing on systemic rather than individual factors that lead to errors and by adopting a nonpunitive approach and culture of safety.
Recommendations
The policy includes the following recommendations for clinicians, practices, institutions, medical educators and researchers:
- Implement office and institutional policies and procedures to identify and disclose medical errors, encourage reporting, and support involved clinicians and staff as part of a nonpunitive culture of safety.
- Identify populations and situations at higher risk of preventable adverse events, and partner with families and care teams to prevent them.
- Increase education on how to identify, prevent and communicate about medical errors in pediatrics.
- Research the impacts of disclosure on patients, families and clinicians, and trends in medical errors and disclosure based on demographics and disease factors.
- Advocate for laws and programs to encourage disclosure, limit liability and support clinicians after medical errors occur.
Dr. Sigman is a lead author of the policy statement and former member of the AAP Committee on Medical Liability and Risk Management.
