Risk Management for Pediatricians

Pediatrics presents distinct clinical and practice management challenges that set it apart from adult medicine. Understanding these challenges is crucial for developing effective risk management strategies and maintaining high-quality patient care.

Diagnostic complexity

The rarity of some conditions, limited capacity for patient communication and cooperation, and normal physiological and developmental changes seen from visit to visit may contribute to the risk management challenges in the pediatric population. All of these factors can lead to delayed or missed diagnoses. Pediatricians must maintain vigilance for unusual conditions that may present only once or twice in their careers. These challenges are compounded by the fact that many rare pediatric conditions require rapid intervention to prevent serious complications, creating a high-stakes environment for clinical decision-making. (1)

Risk management strategies

• Access updated clinical decision support tools and disease databases.
• Document thorough family histories.
• Create a system to document and track unusual symptoms that do not fit common patterns.
• Establish clear protocols for escalating unusual cases to subspecialist referral or emergency care.
• Maintain relationships with pediatric subspecialists for rapid consultation.

Communication and cooperation barriers

Young children’s limited ability to communicate symptoms and cooperate during exams introduces complexity to the diagnostic process. Pediatricians must rely heavily on observational skills and indirect information gathering. The challenge extends beyond basic communication to include accurate pain assessment, medication compliance, and treatment monitoring. These limitations can mask important clinical indicators and complicate the assessment of treatment effectiveness, potentially increasing the risk of adverse outcomes.

Risk management strategies

• Use age-appropriate communication tools, such as visual pain scales or demonstration dolls or models.
• Incorporate play-based assessment techniques for younger children.
• Use validated behavioral assessment tools for non-verbal patients.

‍

Changing patient characteristics

The continuous physical and developmental changes in pediatric patients create additional challenges. Treatment plans must account for changes in weight, height, and maturation, requiring frequent adjustments to medication dosing and therapeutic approaches. This challenge is particularly acute in managing conditions where treatment strategies evolve with the growing child.

Risk management strategies

• Use automated weight-based dosing calculations with safety checks.
• Create structured protocols for medication adjustments based on growth.
• Establish regular review points for chronic condition management.
• Create systematic approaches to reviewing and adjusting care plans.
• Develop tracking systems for developmental milestones and use automated alerts for unusual patterns.
• Use electronic health record (EHR) tools to flag significant changes.
• Establish clear protocols for transitioning care as patients mature.

Complex dependencies in care delivery

The heavy reliance on parents and caregivers as intermediaries in pediatric care creates multiple points where critical information can be lost or misinterpreted. Pediatricians must not only assess the child’s condition, but also evaluate the reliability of parental observations and their ability to follow treatment plans. This dependency can introduce delays in seeking care, inconsistencies in following medical advice, and challenges in monitoring treatment progress.

Risk management strategies

• Document who brought the patient to the visit and is present during the exam.
• If non-parents/guardians request that the patient be brought to visits by others, obtain and document consent.
• Develop standardized templates for collecting parental observations.
• Create structured symptom diaries for parents to track concerns between visits.
• Use teach-back and return demonstration methods to verify parental understanding.
• Provide both oral and written instructions with clear markers for when to seek urgent care.

High-volume practice management

The high-volume nature of pediatric practice introduces opportunities for communication breakdowns and “system” errors.  Pediatric practices must manage rapid patient turnover during sick visits; complex scheduling that accommodates both well-child and acute care needs; high volume of after-hours calls and consults; and comprehensive documentation across multiple interaction points.

Risk management strategies

• Use structured triage protocols for phone calls and messages, and encourage staff to escalate calls or questions to a physician when in doubt.
• Create clear documentation standards for all patient interactions.
• Establish protocols for tracking and prioritizing lab tests, imaging studies, and specialist referrals. Protocols should include how and when to follow up on results and reports.
• Define how after-hours care is managed (internally or externally) and develop protocols as needed.


‍

Documentation

Accurate and timely documentation can support continuity of care and patient safety.

Risk management strategies

• “Medical records should document the outcome of all surveillance and screening activities during preventive care visits. Additionally, specific actions taken or planned, such as scheduling an early follow-up visit, scheduling a visit to discuss developmental concerns more fully, or referrals to medical specialists or early childhood programs and specialists, also should be noted.” (2)

• Update each encounter note to reflect the patient’s current symptoms and to check for unintended EMR system defaults to “normal” or “negative.” The review of systems or exam should not conflict with the history of present illness or chief complaint.
• Briefly reviewing the previous encounter note before walking into the exam room may prompt questions and ways to explore the chief complaint. Consistently updating the problem list will also help subsequent caregivers treating the patient.
• Documenting the patient’s response to the treatment from previous office visits ties the patient encounters together. Previous visit notes, laboratory and diagnostic results, vitals, nursing notes, and communications should be reviewed.
• Document all important patient/parent discussions in the record to ensure that the information is available to other members of the care team.
• Document any discussions with consulting physicians or hospital staff about a patient’s test results, treatment, and recommendations.
• “Among the information important to document are notes on the decision-making process (i.e., information evaluated, rationale for the diagnosis given, treatment recommended and why, consideration of alternative treatments, and rationale for any deviations from usual practice).” (3)

Sources

1. American Academy of Pediatrics. Protecting the practice from medical liability. April 30, 2024. Available at https://www.aap.org/en/practice-management/liability-and-regulation/protecting-the-practice-from-medical-liability/ . Accessed December 16, 2024.


‍
2. Lipkin PH, Macias MM, et. al.  Promoting optimal development identifying infants and young children with developmental disorders through developmental surveillance and screening. American Academy of Pediatrics. Clinical Report. January 2, 2020.  Available at https://publications.aap.org/pediatrics/article/145/1/e20193449/36971/Promoting-Optimal-Development-Identifying-Infants?searchresult=1. Accessed December 17, 2024.

3. Nierengarten M. Strategies to minimize legal risk in pediatric practice. Contemporary Pediatrics. October 26, 2016. Available at https://www.contemporarypediatrics.com/view/strategies-minimize-liability-risk-pediatric-practice . Accessed December 16, 2024.

‍