Pediatric Iatrogenic Deaths

Iatrogenic injury and unexpected hospital death in the newborn

“…The incidence of cardiac tamponade among neonates is 0.18-1.8%, with increased risk when the tip is in the right atrium rather than the vena cava. 7,31 Cardiac tamponade can occur several days after the catheter is placed, suggesting that in some cases the catheter tip erodes the thin myocardium. Microscopic examination of the heart sometimes reveals a site of perforation with hemorrhage and necrosis (Fig.…”

“…Premortem thrombi can usually be readily distinguished from postmortem artifact, but if there is doubt, it can be helpful to fix and examine the thrombus, grossly and microscopically, within its blood vessel. 7 Findings at autopsy may indicate a clear cause of death, or may lead to a final diagnosis after further investigation of the medical record, discussion with clinicians, or postmortem laboratory testing. However, there are cases in which even a comprehensive investigation yields no conclusive result, although possible causes may be suggested by the findings.…”

“…Other useful samples may include fluid collections, vitreous fluid, atrial blood, urine, or cerebrospinal fluid. 7 Some modifications to routine autopsy examination may help reveal the cause of an unexpected neonatal death. If there is clinical concern for a pneumothorax, consider making the initial chest cavity incision under water to visualize escaping air.…”

“…4,5 Errors of drug dosage and delivery are common in children and neonates, and many drugs are not well studied in neonates. 6,7 Neonates are vulnerable to infection, including nosocomial infection, due to immature immune response. Very small body size, delicate tissues, and proximity of structures in a small body increase the likelihood of error in line and catheter placement, and in surgery.…”

“…If drug dose or administration error is a possibility, save all syringes, medication bottles, and intravenous fluid bags at the bedside for possible testing. 7 External examination should include photographs and diagrams documenting any lines, devices, and incisions, as well as skin findings such as needle marks, bruises, and ulcers. A postmortem radiograph may also help document line placement, fractures secondary to birth trauma, and free air in the chest, pericardium, or abdomen.…”