Physicians in various medical specialties provide care to pediatric patients. These physicians include pediatricians, family medicine physicians, emergency medicine physicians, psychiatrists, and surgeons. This report describes findings based on 2,330 cases, including civil legal actions, College, and hospital matters that were closed by the CMPA between 2014 and 2024. For the purpose of this report, a pediatric patient is defined as a patient less than or equal to 18 years of age.
The graph below shows the distribution of medical specialties for 2,650 physicians in 2,330 cases involving pediatric patients.
What medical specialties were involved in medico-legal cases related to pediatric patients? (n=2,650 physicians)
Other specialties included otolaryngologists, diagnostic radiologists, general surgeons, anesthesiologists, neurologists and dermatologists.
The case distribution among physicians in different medical specialties reflects the number of physicians in these specialties. For example, at the end of 2024, the CMPA’s membership included 39,992 family physicians (Type of Work 35, 73, 78 and 79), and 2,974 pediatricians (Type of Work 61). This does not suggest higher risks for family physicians providing pediatric care.
What are the most common patient complaints and peer expert 1 criticisms? (n=2,330 cases)
| Deficient assessment |
43 |
18 |
| Diagnostic error |
35 |
22 |
| Unprofessional manner |
25 |
8 |
| Inadequate communication with patient or family |
20 |
13 |
| Failure to perform test or intervention |
16 |
9 |
| Inadequate office procedure |
11 |
9 |
| Failure to refer |
11 |
5 |
| Inadequate consent process |
11 |
6 |
| Professional misconduct |
10 |
4 |
| Inadequate monitoring or follow-up |
10 |
6 |
Complaints are a reflection of the patient’s perception that a problem occurred during care. These complaints are not always supported by peer expert opinion. Peer experts may not be critical of the care provided or may have criticisms that are not part of the allegation by the patient, parents or caregivers.
Inadequate communication between the physician and the patient, parents or caregivers is a frequent complaint and peer expert criticism. Examples of communication concerns include:
- The parents of an infant with a possible hip dysplasia alleged that the physician failed to answer their questions, dismissed their perceptions, and proceeded to prescribe unnecessary treatment.
- The parents of a preschool asthmatic child alleged that the physician dismissed parental concerns and did not properly communicate the treatment plan to the parents, which led to early discharge of the patient causing them to return a few hours later for additional treatment.
- The parents of a school-aged child with diabetic ketoacidosis symptoms alleged that the physician did not communicate the severity of the patient’s condition and did not advise them to go to emergency right away, thus delaying the proper treatment.
- The parents of an adolescent with new onset cardiac symptoms alleged that the physician failed to provide further instructions against physical activity to reduce the risk of having further cardiac symptoms.
Unprofessional behaviour by a physician is a frequent complaint. Examples include:
- The parents of a preschooler with polyuria and polydipsia alleged that a physician was dismissive, intimidating, and had made mocking comments during the examination of their child.
- The parents of a school-aged child presenting with insomnia complained that a physician made inappropriate comments to the child and questioned the parents’ parenting skills.
What are the most frequent patient conditions?
The table below shows the most frequent patient conditions in 4 age groups: infants/toddlers (under 2 years old), preschool-aged (2-4 years old), school-aged (5-12 years old), and adolescents (13-18 years old).
Infants/toddlers (under 2 years old, n=465 cases)
- Ear (e.g. otitis media)
- Respiratory (e.g. acute infections, pneumonia, bronchiolitis)
- Gastrointestinal (e.g. enteritis, colitis)
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- Musculoskeletal malformations (e.g. plagiocephaly)
- Organ malformations (e.g. atresia of bile ducts, tetralogy of Fallot)
- Reproductive organ abnormalities (e.g. undescended testicles)
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- Head (e.g. subdural hemorrhage)
- Upper extremities (e.g. fractures)
- Lower extremities (e.g. fractures)
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Pre-school aged (2-4 years old, n=349 cases)
- Ear (e.g. otitis media)
- Respiratory (e.g., acute infections, pneumonia)
- Skin (e.g. molluscum contagiosum)
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- Head (e.g. minor lacerations)
- Upper extremities (e.g. fractures)
- Burns
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- Childhood autism
- Attention deficit hyperactivity disorder
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School-aged (5-12 years old, n=771 cases)
- Respiratory (e.g. upper respiratory infection, pneumonia)
- Skin (e.g. viral warts, molluscum contagiosum)
- Otitis media and viral gastroenteritis
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- Head (e.g. uncomplicated wound injuries)
- Upper extremities (e.g. fractures)
- Lower extremities (e.g. fractures)
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- Attention deficit hyperactivity disorder
- Conduct disorders
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Adolescence (13-18 years old, n=749 cases)
- Head (e.g. concussions)
- Upper extremities (e.g. fractures)
- Lower extremities (e.g. fractures)
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- Depression
- Anxiety/general anxiety disorder
- Bipolar disorder
- Mood disorders
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- Respiratory (e.g. pharyngitis)
- Skin infection (e.g. viral warts)
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- Attention deficit hyperactivity disorder
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Frequencies of patients’ conditions among medico-legal cases are likely representative of physicians’ practice patterns and do not necessarily reflect high-risk conditions. There may be more than one presenting condition documented on one case. One case may have more than one patient involved.
In 517 cases, the patient experienced a diagnostic error, including misdiagnosis, missed or delayed diagnosis. In 56% (291/517) of these cases, peer experts had a criticism of the physician’s deficient patient assessment. For example:
- A failure to broaden the possible diagnosis to explain severe respiratory distress in an infant led to a missed diagnosis of an underlying metabolic disorder.
- A failure to thoroughly assess an adolescent following a bicycle accident contributed to a failure to order a test (abdominal CT) and thereby contributed to a missed diagnosis of a splenic laceration.
In 31% (161/517) of cases involving diagnostic error, peer experts criticized the provider’s inadequate documentation. For example:
- During multiple virtual visits with a school-aged child, a physician used a preformatted template that did not include reason for visit, a thorough review of systems, symptoms details, clear treatment plan, diagnosis (with differential diagnosis) or follow-up. This contributed to the delay in referring the patient to the emergency department and delay in diagnosing the patient with diabetic ketoacidosis.
- A peer expert noted that the physician failed to include sufficient information regarding recent illness, sick contacts, medical history, vital signs and general appearance for a school-aged child with pneumonia. There was no documentation as to the rationale and choice of antibiotic. The child received an incorrect diagnosis and was provided with incorrect antibiotic treatment.
What are the factors associated with severe patient harm 2 in medico-legal cases? (n=2,330 cases)
Patient factors 3
Presenting with:
- Diabetes mellitus
- Inflammatory diseases of the central nervous system
- Episodic and paroxysmal disorders
- Influenza and pneumonia among infants
- Severe bacterial infection, including sepsis
Having comorbidity conditions of:
- Obesity and other hyperalimentation disorders among adolescents
- Mental and behavioral disorders among adolescents due to psychoactive substance use
- Congenital malformations of the circulatory system
- Congenital malformations, deformations and chromosomal abnormalities
Provider factors 4
- Deficient assessment
- Failure to perform test/intervention
- Failure to refer
- Failure to attend (e.g. failing to assess a patient personally and relying solely on a resident’s assessment)
- Poor decision-making regarding management (e.g. not referring patients to the emergency department to confirm suspicion of new onset diabetes)
- Premature discharge (e.g. discharging an immunocompromised patient with fever without treating them with antibiotics)
Team factors 4
- Communication breakdown with other physicians
- Inadequate discharge instructions to patient, parents or caregivers
- Inadequate documentation
System factors 4
- Inadequate office procedure (e.g. failing to have physician coverage or follow-up for patients during vacation or absence, failing to have a policy to schedule longer appointments to complete a thorough assessment)
Risk reduction reminders
An in-depth review of medico-legal cases related to physicians treating pediatric patients highlights the following risk reduction considerations.
- Maintain awareness of pediatric patient history, including birth history, developmental milestones, co-morbidities, current medications, and vaccination history. Conduct assessments and investigations that are appropriate to the patient’s age.
- Take time to pause and reflect on the differential diagnoses, being careful to consider possibilities that may be life-threatening (e.g. diabetic ketoacidosis, meningitis, sepsis). Consider obtaining a second opinion when unsure of your diagnosis.
- Provide comprehensive discharge instructions to patients, parents or caregivers, both verbally and in writing, including medications, follow-up care, symptoms/signs to monitor, and guidance on when to seek medical attention. Provide clear information on when and who to contact in case of complications. Confirm patients’ or parents’ understanding of the information being provided.
- Document the patient's history (include symptoms and co-morbidities), physical exam findings, reassessments, investigations, differential diagnoses and suspected or confirmed diagnosis, including diagnostic reasoning. Include any treatment plan and follow-up instructions that have been shared with the patient, parents or caregivers. It is also important to include any communication(s) with other specialists or providers who are involved in the care of the patient.
Limitations
The numbers provided in this report are based on CMPA medico-legal data. CMPA medico-legal cases represent a small portion of patient safety incidents. Many factors influence a person’s decision to pursue a case or file a complaint, and these factors vary greatly by context. Thus, while medico-legal cases can be a rich source for important themes, they cannot be considered representative of patient safety incidents overall.
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Notes
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Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
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Includes severe patient harm and death. In the CMPA Research glossary, severe patient harm is defined as symptomatic, requiring life-saving intervention or major medical/surgical intervention, or resulting in a shortened life expectancy, or causing major harm or loss of function.
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Patient factors include any characteristics or medical conditions that apply to the patient at the time of the medical encounter, or any events that occur during the medical encounter.
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Based on peer expert opinions.
