Battery in Toddler’s Nose Missed at First

A parent brought their toddler to an urgent care facility for a swollen nose and nasal trauma after the child ran into a screen door. X-rays were performed at the visit. The following day, the radiologist reviewed the studies and noted a foreign body resembling a battery in the child’s right naris with no evidence of fracture. The urgent care facility called the parents and told them to see their pediatrician. A handwritten note on the X-ray itself documented that the parent was informed of the foreign body, but the parent later claimed they did not receive this information.

The parents did bring their child to the pediatrician’s office, and a nurse practitioner saw the patient. The parents told the NP about the patient’s recent injury and stated the X-rays from the urgent care visit were normal. The NP did not have access to the urgent care notes and did not attempt to obtain them. The exam notes included swelling and bruising around the right eye and the bridge of the nose. The NP ordered follow-up X-rays and told the parents to return in three days. The parents reported the wait in radiology was too long, the X-rays were never completed; and the child and parents never presented for the scheduled follow-up visit.

They returned to the practice two weeks later, reporting intermittent nose bleeds, and the pediatrician documented a normal exam, except for dried blood in the right naris. They diagnosed nosebleeds due to dry weather and nose-picking. The family returned again nine weeks later because the child had been experiencing malodor and nasal discharge. A different pediatric provider referred the family to an ear, nose, and throat physician.

But the following day, the child was brought to the emergency department with significant nosebleeds. It took six days for insurance approval for an ENT, and 11 more days to be seen. Five days after the evaluation, the ENT performed surgery to remove the object and found multiple pieces of a button battery. The battery had decomposed and leaked acid, which had damaged the nasal septum and part of the bone, causing a large anterior nasal septal perforation. As a result, the child may require additional surgery for cosmetic issues related to the perforation.

The parents alleged that a delayed diagnosis of a foreign body in their child’s nose caused preventable nosebleeds, nasal infection, nasal septal perforation, and the need for surgery. The malpractice claim named the pediatric group, two pediatricians, and a pediatric nurse practitioner.

The case was settled in the low range.

To help discuss the risk management and patient safety issues in this case, we are joined by Dr. Jonathan Einbinder. Dr. Einbinder is an internist in urgent care at Brigham and Women’s Hospital in Boston and Vice President for Advanced Data Analytics and Coding for CRICO.

Q.) Hi, Jonathan. There are a couple of unusual features in this case and also sort of classic patient safety risks and those can lead to malpractice cases like this.

A.) Hello, Tom. Yeah, this one also scares me a little bit as an urgent care provider. I could see every step of the way where a mistake is made, how that mistake happened, and could see it happening to me or people that I work with. So it’s also a bit scary in in that regard.

You know, when I read through the case, I made a list of some of the different, patient safety issues that occurred in this case. There are multiple providers involved in the care of this patient and the family. There are communication issues with their family, problems with access to information, and sometimes a lack of awareness of previous care and previous decisions. There’s difficulty or failure in closing the loop on abnormal test results, execution of orders and, instructions for patient follow up. There’s unclear accountability for follow up and closing the loop, and also unclear service level expectations in terms of what a provider is expected to do and what the family and patient expect the providers to do. There are and finally, there are documentation issues and issues with access to care and the pace of care. In particular, how long it took to execute the referral in this case.

Q.) So it’s got all this stuff, where do you want to start?

A.) I think the critical mistake in this case really occurred at the beginning. And the, you know, the child presented to urgent care with a traumatic injury. As part of the evaluation, an X-ray was performed and the foreign body, the battery in the child’s nose was noted the next day by the radiologist. And the urgent care reports that they called the parents and told the parents that the child needed to be seen by the pediatrician. The parents say that they weren’t informed that there was a foreign body. I think that really was the critical dropping of the ball.

The piece of this and I think the lesson that, I always keep in mind as an urgent care provider, and I’ll also be very, very honest, which this doesn’t always happen, is that when there’s an abnormal study, something that is a critical finding that requires follow up, the provider who finds that, or ordered the test, finds the result, knows about it, has responsibility for that result until it’s communicated and another provider explicitly assumes responsibility for it until there’s really a handoff. And that didn’t happen in this case. And I think everything else that follows, there are multiple errors, multiple holes in the cheese, so to speak, really are the sequelae of that initial failure to convey that result and ensure the handoff of responsibility.

Q.) Now, the diagnosis was further delayed later, when the radiology referral wasn’t tracked by the PCP, and it never happened. Can you talk about that piece?

A.) You know, when the child was seen in the pediatrician’s office in follow up, the follw up X-ray studies were ordered. And plans were made for the child to return to the clinic for evaluation in three days, but the X-rays didn’t happen. And the follow up visit also didn’t happen. The closing the loop on whether or not the X-ray order was executed and whether or not the follow up was executed, again, really falls on the provider who saw the patient, at that pediatrics visit.

Having said all that, there are a number of, policies, procedures, mechanisms in place to help ensure that the loop does get closed. Often the electronic health record will highlight for the provider that there’s an order, an X-ray order that was made and that the X-ray wasn’t performed. I know, and my practice, our electronic health record system will do that for me.

So it’s something where there is a real need for systems level solutions. Also, again, clear accountability and responsibility for the ordering provider and the expectation that they are going to follow up on that or that the followup is delegated to somebody else in the practice who might be following these orders and seeing what is executed and what isn’t.

Q.) Looking to prevent this kind of case in the future, what are the key questions that every practice should ask itself? Is there any one of those that is a priority?

A.) Yeah, it’s a great question. And I think starting again at the very beginning, the very clear, expectations on the part of the providers as to who is responsible or following up on test results. Is it the ordering provider? Is it the primary care provider? Is it a designated other provider, for example, a nurse practitioner or a PA or a nurse in the practice who follows up on all results? And I think the, you know what, what I would suggest there and what happens in my own urgent care practice is that I am responsible for tests that I order, unless or until I explicitly hand it off to the primary care provider, and that they accept the responsibility for doing that.

So I think having clear expectations and knowing basically who is responsible for following up on these things and making sure it happens is a first question to ask.

I think the second question is which things really need to be followed up on? And this is a bit tricky. You know, one might expect that every test result, every referral, every follow up visit that’s supposed to be scheduled should have the loop closed and should be followed up on. But not all follow up visits, not all tests are equally important, and for some it’s critical that follow up happens.

It’s a hard judgment to make, and it does introduce the potential for important things to fall through the cracks. On the other hand, following up on everything can be overwhelming to the provider and to the practice.

The third question might have to do with, has this been communicated to the family or patient and do they understand, what the plan is? And by communicated what is communicated verbally and documented what they’ve done in writing? Are there any concerns about understanding or capacity or language or other issues in terms of being barriers to follow up? So I think that might be the third question I would put in here. That that communication between providers and patients is really cricital.

That is a contributing factor, by the way, that when we look at malpractice claims is very common. and, you know, very, very difficult to, very difficult nut to crack. But it’s something that we do see in many malpractice cases across multiple allegation types and case types.

Q.) We do see some old-fashioned documentation problems here. I mean, at some point they were writing on the X-ray, I guess.

A.) Yeah. Well, there are clearly documentation issues here and the documentation really has two aspects here. And the first reflects the importance of documentation for good patient care and good patient safety. Documentation is a way of communicating to other providers. It’s a way of communicating to the patient and family, especially since our patients now have access to our visit notes and can and do read them. So there’s the patient safety and quality aspect. And in fact, I think I did notice in this case the second visit in pediatrics was a different provider than the nurse practitioner that saw the patient for the first visit. And this is when the child presented with nosebleeds. From my reading and inference of what happened, that provider didn’t have any context for why the child was presenting and the prior history, and assumed that the child simply was having nosebleeds because of having a dry nose and from nose picking. It didn’t even occur to them, or they didn’t know that there was this foreign body history. So documentation to communicate to other providers is really important.

But the other aspect I want to highlight is the documentation in terms of how it can both mitigate the malpractice risk and also can aid or hinder the defensibility of malpractice claims. I’ll take a moment here to say that here at CRICO, we, have looked at, cases where there’s insufficient documentation that is coded in malpractice cases as a contributing factor. And the odds of closing with payment for those cases is nearly double what it is for cases that don’t have that contributing factor.

So it really speaks to the importance of documenting both the clinical rationale for decisions, but also documenting, in this case, the communication to the family, and documenting the plan that can mitigate the future malpractice risk, and if there is a malpractice claim, aid in the defensibility, of the claim. In this case, I’m assuming that, again, I don’t know, for sure, that in the medical record, the providers were documenting that they communicated these things. Even there, you know, having done it in writing, in the record that’s printed out for the patient would have been, you know, much stronger evidence that that communication had happened.

So I do think documentation is absolutely a critical aspect of, of this case as well.

Q.) Well thank you, Jonathan. These are great insights and thank you for sharing them. Doctor Jonathan Einbinder is Vice President for Advanced Analytics and Coding at CRICO and an internal medicine physician at Brigham and Women’s Hospital in Boston. I’m Tom Augello for MedMal Insider.