AlanSchroeder, MD, Dept of Pediatrics (Hospital Medicine and Critical Care), Stanford University School
of Medicine, Associate Editor, Hospital Pediatrics
“Bending the Value Curve” is an ongoing series in Hospital Pediatrics that features stories involving hospitalized pediatric patients who are victims of
low-value care. This series was motivated in general by the pressing need to improve
value in US healthcare and specifically to address the imbalance between stories involving
“omission errors” (patients harmed because of failures to diagnose and treat promptly)
and “commission errors” (patients harmed from unnecessary testing or treatment). Historically,
omission errors tend to get more attention in the media and in our everyday vernacular
(“I can’t believe I missed that”), and tend to be judged more harshly, so one goal
of the Bending the Value Curve series is to shift this imbalance. We have published
dozens of these stories, often submitted by trainees, and covering an array of inpatient
In this month’s issue we feature “It’s Okay to Blink and Miss It” by McManus et al
(10.1542/hpeds.2019-0022), a story about a 9-year-old boy who was noted by his pediatrician to have repetitive
blinking during a well-child visit. The blinking had not been bothersome to the patient
or his family, but prompted strep testing by the pediatrician out of concern for PANDAS.
Cefdinir was prescribed when the rapid strep turned positive, and the cascade began…
The patient developed diarrhea and abdominal pain which in turn prompted multiple
revisits, probiotics, stool cultures and O&P, administration of an anti-protozoal
agent, and an abdominal ultrasound and CT scan. The findings from the CT scan prompted
admission to the hospital for further workup for possible inflammatory bowel disease.
Mercifully, a C. diff PCR returned positive right before the endoscopy/colonoscopy
was scheduled to occur.
Sound familiar? We’ve all seen similar cases of well-intended, even “thorough”, care
that triggers a cascade of mishaps and harm. For this case, one could even envision
an initial sense of triumph on the part of the ordering provider when the strep test
returned positive, and perhaps a sense of “thank goodness they found it” on the part
of the family.
We must continue to tell these stories – in journals, in talks, in morning reports
and noon conferences, and in our daily clinical lives. When we debrief adverse events
following medical interventions, we must consider the necessity of the intervention
in the first place. Keep sending us your stories!