“Bending the Value Curve” is an ongoing series in Hospital Pediatrics that features stories involving hospitalized pediatric patients who are victims of low-value care. This series was motivated in general by the pressing need to improve value in US healthcare and specifically to address the imbalance between stories involving “omission errors” (patients harmed because of failures to diagnose and treat promptly) and “commission errors” (patients harmed from unnecessary testing or treatment). Historically, omission errors tend to get more attention in the media and in our everyday vernacular (“I can’t believe I missed that”), and tend to be judged more harshly, so one goal of the Bending the Value Curve series is to shift this imbalance. We have published dozens of these stories, often submitted by trainees, and covering an array of inpatient topics.
In this month’s issue we feature “It’s Okay to Blink and Miss It” by McManus et al (10.1542/hpeds.2019-0022), a story about a 9-year-old boy who was noted by his pediatrician to have repetitive blinking during a well-child visit. The blinking had not been bothersome to the patient or his family, but prompted strep testing by the pediatrician out of concern for PANDAS. Cefdinir was prescribed when the rapid strep turned positive, and the cascade began… The patient developed diarrhea and abdominal pain which in turn prompted multiple revisits, probiotics, stool cultures and O&P, administration of an anti-protozoal agent, and an abdominal ultrasound and CT scan. The findings from the CT scan prompted admission to the hospital for further workup for possible inflammatory bowel disease. Mercifully, a C. diff PCR returned positive right before the endoscopy/colonoscopy was scheduled to occur.
Sound familiar? We’ve all seen similar cases of well-intended, even “thorough”, care that triggers a cascade of mishaps and harm. For this case, one could even envision an initial sense of triumph on the part of the ordering provider when the strep test returned positive, and perhaps a sense of “thank goodness they found it” on the part of the family.
We must continue to tell these stories – in journals, in talks, in morning reports and noon conferences, and in our daily clinical lives. When we debrief adverse events following medical interventions, we must consider the necessity of the intervention in the first place. Keep sending us your stories!
