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ARTICLE |
a Center for the Advancement of Perioperative Health and Departments of Anesthesiology
b PediatricsChild Psychiatry, Yale University School of Medicine, New Haven, Connecticut
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. Data were obtained from the National Practitioner Data Bank.
RESULTS. the period from February 1, 2004, through December 31, 2005, a total of 30195 malpractice payments were made on behalf of practitioners in the United States; 14% of those payments (4107 of 30195 payments) were child related. During the period analyzed, $1.73 billion were paid for malpractice cases involving children. More than 95% of all payments were the result of settlements and only 
5% the result of judgments. The average child-related malpractice payment was significantly greater than an adult-related malpractice payment ($422000 vs $247000); however, child-related malpractice payments were only one half as likely to occur, compared with adult-related malpractice payments. Significant geographic variability was found in the numbers and sizes of child-related malpractice payments. Failure to diagnose was the leading reason for child-related payments (18%), followed by improper performance (9%), delay in diagnosis (9%), and improper management (6%). Finally, we found that 40% of all malpractice awards were the result of surgical or obstetrical issues.
CONCLUSIONS. Practicing pediatricians should be aware of the existence of a mandatory electronic depository that documents all malpractice settlements and judgments involving practitioners.
Key Words: malpractice • National Practitioner Data Bank • pediatricians
Abbreviations: NPDB—National Practitioner Data Bank
Medical malpractice is a problem of major importance for practicing pediatricians in the United States. Indeed, although few malpractice cases were reported in the early 20th century, such cases are common today.1 The Division of Health Policy of the American Academy of Pediatrics has monitored pediatrician medical liability since 1987, through the Periodic Survey.2 Although this is a valuable source of information, it is susceptible to all of the biases of a survey. Another source of information regarding malpractice payments involving pediatricians is the Physicians Insurers Association of America.3 This organization, which includes insurances that cover 60% of the US population, publishes annual reports regarding closed malpractice claims. Although this information is highly valuable, it is not inclusive of all malpractice cases involving children in the United States.
The National Practitioner Data Bank (NPDB) is an electronic depository that identifies practitioners with a history of adverse actions and medical malpractice payments.4 The NPDB was established with the intent to limit the possibility of a provider simply moving from hospital to hospital or from state to state to avoid the repercussions of a malpractice suit or other disciplinary action. This mandatory reporting system was established to execute the Health Care Quality Improvement Act of November 14, 1986. The NPDB, under the authority and direction of the Department of Health and Human Services, contains data from September 1990 to the present.5 The NPDB includes data regarding all payments made in the United States on behalf of practitioners for malpractice settlements or judgments. All insurance companies in the United States are obligated by law to report such payments to the NPDB. Other information included in the NPDB includes disciplinary actions that were taken concerning licensure, clinical privileges, and standing in professional societies. When information is received about a given provider, that person is notified, with a copy of the report being posted. Providers who disagree with the entry can attempt to settle the dispute with the reporting entity; if they are unsuccessful, they can add a statement to the report or dispute the report. Readers should note that NPDB reports are required for malpractice payments involving all types of licensed health care practitioners.
Until January 31, 2004, the NPDB contained no information regarding the age of the patient involved in the malpractice payment; therefore, any age-based analyses of these data were impossible. Since February 1, 2004, age information has been included in NPDB data, and it is now possible to review child-related NPDB malpractice payment information. Therefore, the purpose of this report is to describe the particular characteristics of malpractice payments involving children from birth through 19 years of age in the United States in the past 2 years.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Information obtained from the NPDB included malpractice payment amounts and basic demographic features of the practitioners and patients. Clinical data were limited to variables such as malpractice allegation group (eg, anesthesia related, surgery related, or medication related), specific malpractice allegation (eg, failure to monitor or delay in diagnosis), and severity of alleged malpractice injury (eg, death, temporary injury, or emotional injury). Each practitioner reported in the NPDB has a unique identification number, which enables analysis of the number of payments for any practitioner. Interested readers are referred to the NPDB Web site for more-detailed information (www.npdb-hipdb.com). To evaluate geographic variability in the frequency of NPDB payments, we divided the number of malpractice claims in an individual state by the state's population (in units of 100000) of children 
19 years of age.6
Data were analyzed with frequency analysis and 
2 analysis; data regarding payment amounts were highly skewed and therefore are presented as medians. Significance was accepted at P = .05. Data were analyzed with SPSS 14.0 software (SPSS Inc, Chicago, IL).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Eighty-three percent of malpractice payments involving children were made on behalf of physicians, 7.2% were made on behalf of dentists, and 5.2% were made on behalf of nurses. The remaining 4.2% of payments were made on behalf of various other types of licensed health care professionals. Of note is the fact that 53 residents were involved in malpractice related to children.
A total of 3772 practitioners were involved in the 4071 pediatric NPDB malpractice cases. That is, 92.6% of practitioners had 1 medical malpractice payment report against them, compared with 6.7% of practitioners who had 2 medical malpractice payment reports against them, and 0.7% practitioners who had 3 or 4 medical malpractice payment reports against them. Of note, there were 2 practitioners with >4 payments (11 payments and 15 payments) made on their behalf during the 23 months of the report.
More than 95% of malpractice payments involving children (3918 payments) were awarded as a result of settlements; judgment payments included only 110 cases. Approximately 28% of all child-related malpractice cases were diagnosis related, 10% were surgery related, 3% were anesthesia related, 28% were obstetrics related, 22% were treatment related, and 6% were monitoring or medication related. Failure to diagnose was the leading cause of child-related payments (18%), followed by improper performance (9%), delay in diagnosis (9%), and improper management (6%).
Significant geographic differences were found when the frequencies of malpractice payments were analyzed according to state (Table 1). Indeed, with adjustment for the size of the respective state populations 19 years of age, the District of Columbia, New York, New Jersey, Pennsylvania, and Louisiana were the states with the highest frequencies of payments. Idaho, Alabama, Minnesota, Tennessee, and Virginia were the states with the lowest frequencies of pediatric malpractice payments.
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19 years of age. The average amount of a child-related malpractice payment was significantly greater than the average amount of an adult-related malpractice payment ($422000 vs $247000). The largest child-related malpractice payment during the study period was $22500000, which was awarded to a boy <1 year of age whose outcome was described as "quadriplegic, brain damage, lifelong care" after he underwent anesthesia and surgery. Overall median payments for the pediatric population differed significantly on the basis of the severity of injury ($42500 for emotional injury, $22500 for minor temporary injury, $82500 for major temporary injury, $245000 for significant permanent injury, $795000 for quadriplegia, brain damage, or lifelong care, and $195000 for death). As can be seen from Table 2, median malpractice payments were significantly greater among children <1 year of age. It should be noted, however, that the severity of injury that resulted in malpractice payments varied significantly according to age group. Although permanent injury was the leading cause of all malpractice payments, the high frequency of brain injury in the <1-year-old group and the high frequency of death in the >60-year-old group should be noted (Table 2).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Previously, pediatricians were thought to be shielded from malpractice lawsuits, to some degree. Although we found that practitioners involved in the care of children were significantly less likely to be sued, compared with practitioners who care for adults, NPDB data indicated that child-related malpractice lawsuits are not uncommon and may result in significant malpractice payments. Children present a unique set of problems for health care providers, that is, they have decreased ability to communicate with health care providers, they have different physiologic features, and they are more prone to medication errors; these can explain the increasing frequency of malpractice payments for children.
The current medical malpractice crisis is very relevant to pediatricians, and pediatricians need to be aware of the various issues associated with a higher likelihood of a malpractice payment. Approximately one half of child-related malpractice payments were awarded because of diagnosis and treatment issues. As expected, children <1 year of age who had a diagnosis that necessitated care for their entire life were awarded the highest payments.
The NPDB is a high-profile, nationwide database that captures information on physicians, dentists, and other health care practitioners. Although its primary function is to provide information to hospitals, health plans, professional societies, state licensing boards, and other eligible health care entities, it also represents a unique opportunity for monitoring of malpractice data. Longitudinal data can be collected and trends such as increases in the incidence of malpractice payments over time can be investigated. However, the limitations of this study and the database should be noted. First, no meaningful clinical data are available in the database and thus no conclusions can be drawn regarding improvements in clinical practice. Second, the database might underrepresent the actual payments made, because hospitals might reach settlements with patients with the condition that the physicians would be dropped from a lawsuit. This is speculation, however, and cannot be quantified. Although data regarding adverse actions against practitioners are available in the NPDB, those data were not within the scope of this report. We also note that the quality of the NPDB data regarding adverse actions against practitioners was criticized recently as being incomplete.8 In contrast, data regarding malpractice payments are complete, and the reporting of such data to the NPDB by insurance carriers is mandatory.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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40% of all cases were a result of surgical or obstetrical issues. Much variability was observed within the United States, both in terms of incidence of malpractice payments (after adjustment for population size) and in terms of median payment amounts. Also, much variability was observed with regard to the type of case involved; that is, general pediatric malpractice awards were significantly lower than malpractice payments awarded for obstetrical or surgical reasons.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Zeev N. Kain, MD, MBA, FAAP, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510. E-mail: kain{at}biomed.med.yale.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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