Ms. N, 49, was a pediatric nurse practitioner who worked in a private office practice for Dr. P, the pediatrician, for 15 years. Many of the practice’s patients began seeing Dr. P or Ms. N at birth. 


One of these new patients was 3-week-old Baby B, whose mother brought him in for his first well-baby examination. At that visit, Dr. P examined the baby and identified mild jaundice and a possible failure to thrive, and he noted this in the child’s file.


The patient was not brought in again until age 6 months. At this visit, Ms. N examined him for the first time and documented in his chart that he was developing normally. The next well-baby visit was scheduled, but the patient’s mother missed it, as well as an appointment that was scheduled following that one. When the office staff called to remind the mother that she had missed appointments, she asked to speak to Ms. N. 


“Sometimes my baby looks cross-eyed,” the mother said. “Is that normal?”


Ms. N was used to new mothers calling with similar questions and reassured the mother that this can be normal in infants. However, she recommended scheduling an appointment in the next week for a follow-up, so we can check him out. An appointment was scheduled, but the patient’s mother did not keep it. 


Six weeks later, however, when Baby B was aged 10 months, his mother brought him in for a checkup, and Ms. N examined him for the second time. At this visit, Ms. N noted that the baby’s eyes would cross periodically, as the mother had mentioned over the phone, and he showed signs of developmental delay, including being unable to sit up or crawl. Ms. N left the exam room to consult with Dr. P, and both clinicians agreed that referral for a neurological exam was warranted.