Closing the Disclosure Gap: Medical Errors in Pediatrics

“Look at her. She doesn’t look right,” a worried mother explained to me. About a week ago, her daughter, Ada, an infant with complex congenital heart disease, had been admitted for evaluation of new-onset seizures. I joined Ada’s care team several days after she had been admitted. Her mother noted that since Ada had arrived at the hospital, her feeding had become lackluster, she was sleeping less, and she was fussier than usual. Ada squirmed uncomfortably in bed while her mother untangled the numerous plastic wires that helped connect her to the electroencephalogram machine. Although Ada’s preliminary electroencephalogram results revealed seizures, none of them correlated with her episodes of unrest. After pursuing several workups that ultimately led to dead ends, it soon became clear that her deterioration was due to worsening fluid overload. The admitting medical team had reordered an old home dose of diuretic that had not been weight-adjusted since her last admission. The dose was appropriately increased, and Ada’s condition improved. I sat down with Ada’s mother and, to the best of my abilities, explained what had happened. Ada’s mother, although upset, was appreciative of the timely disclosure and relieved that we had identified the cause of Ada’s symptoms. Ada’s medical error is not an uncommon occurrence. Recent data suggests that medical errors may be the third leading cause of death … Address correspondence to Hannah Famiglietti, MD, Department of Pediatrics, New York University, 550 1st Ave, New York, NY 10016. E-mail: hannah.famiglietti{at}nyulangone.org