- Jonathan Einbinder, MD
[Dramatization: family memory]
My mother was coughing and having trouble breathing, so she went to the doctor and they thought she had pneumonia. She ended up seeing 3 doctors, and they all missed what she really had, which was a blood clot. I can’t even believe I’m saying this; it all happened within a week. She called them again, and all they gave her was a refill for her inhaler. She died the next day.
A 55-year-old female patient had a history that was significant for obesity, hypertension, asthma, and anxiety. She presented to Urgent Care complaining of shortness of breath, hemoptysis, and persistent cough for three days. She reported pain (6–7/10) in her posterior right shoulder and right calf. The nurse’s assessment revealed a pulse of 120 and a 94% oxygen saturation on room air. These were documented in handwritten notes, to be entered later into the patient’s electronic health record. The family medicine physician on duty examined her, but did not review the nursing notes, and during the exam, the patient only complained of cough and hemoptysis. So the physician and the patient never addressed the tachycardia and low O2 saturation or the patients complaint of pain. The doctor ordered a chest x-ray, and the wet read revealed cardiomegaly and the possibility of slight infiltrates. The patient was given a prescription for Levaquin for potential pneumonia.
The final radiology report noted marked cardiomegaly on the x-ray, and mild central pulmonary vascular prominence and no infiltrates. The radiologist recommended a chest CT scan if hemoptysis persisted. The patient was not informed of this result.
Three days later, the patient returned to the Urgent Care clinic with continued shortness of breath but she denied any calf pain at this time. Her own PCP examined her. Her cough prevented her from lying flat at this visit, and examination revealed a pulse of 130, O2 saturation of 96% on room air, and clear lungs.
During a stat cardiology consult the cardiologist saw the patient without access to the PCP’s notes, which had not yet been entered. The patient declined a stat echocardiogram, instead scheduling it for the following week. A pulmonary consult was ordered.
Two days later, the patient called her PCP complaining of “coughing up more dark red blood” and requesting a refill on her inhaler, and that was ordered. Within 24 hours of this phone call, the patient died of a massive PE. Autopsy revealed the patient had been showering emboli for weeks.
The patient’s family alleged that both family medicine physicians, the nurse, the radiologist, and the cardiologist were negligent for failing to diagnose pulmonary embolism. The nurse, radiologist, and cardiologist were eventually dropped from the case, which was settled in excess of $1M.
To discuss the patient safety and risk management aspect of this case, Dr. Jonathan Einbinder joins us now. Dr. Einbinder is an urgent care provider in Boston, and is Vice-President for Advanced Data Analytics and Coding at CRICO.
Q.) Jonathan, thank you for joining us, what jumps out at you right away as we start to think about preventing this kind of tragic case outcome?
A.) I think it probably went wrong at the very beginning. When the patient comes in, especially to urgent care, you know, the patient comes in with a complaint, and as an urgent care provider — and, by the way, that’s what I do for my clinical practice is urgent care — you often have a working diagnosis. You have an opinion about what the case is likely to be. You’ve already, to use the epidemiologic term, you already have a framing bias. You’ve got a presumptive diagnosis on how you think things are going to go. This patient came in and was thought to be a pneumonia patient or a hemoptysis patient, and hemoptysis is when there is blood that is being coughed up. Those things can be urgent or emergent, but they don’t have to be. As long as she is not massively bleeding and as long as she is not unstable, then the treatment would be quite appropriate, to give her antibiotics and send her home and watch and see what happens, which is what they did. The issue I suspect was really one of two things, and it’s either the failure to consider pulmonary embolism in the differential diagnosis, or a framing bias, again to use the epidemiologic term. Not considering the diagnosis would be one potential issue, and there’s a lot of reasons that could happen. Again, we’re human, everybody’s human, and you can forget, you cannot think about it, you could be busy, distracted, behind in your schedule. You know, there’s lots of reasons to not think about it.
The other problem has to do with one of patient assessment, which is then when you’re actually evaluating the patient. It is, what they look like, how fast they’re breathing. In this case, one of the things that really stuck out is she had a very high heart rate, a tachycardia. I think her heart rate was recorded at 120. That to me would be a big red flag that something is going on. And that would raise my suspicion that I needed to do something here beyond just, you know, send her home.
Q.) How do you avoid the trap of focusing too narrowly on a single sort of diagnostic theory?
A.) I guess I would divide those into two categories. One is a set of system things and the other is a set of individual things. And the individual things are the ones we always think about, which is, either ask a student or be asked if we were students, have you considered PE? That was always, you know, the questions for the resident or the attending. You’d be presenting a case and they’d say, have you thought about pulmonary embolism? So it’s one of those things you always were schooled to think about, but now you’re relying on the individual to remember to do that. Vowing to remember is not a successful quality improvement strategy.
The other approach is now you need to figure out how to build things into the system. That’s a very hard thing to do, but there some things can be done right. So one of them would be to leverage the team so you don’t rely on the individual as much. In this case, there’s a nurse who did the triage and took the phone call and did the vital signs and talked to the patient, and that information wasn’t readily communicated to the physician. I don’t know what communication happened, but it wasn’t communicated, it wasn’t highlighted — the concerns of the nurse who may have been thinking of PE at that point. You know, there’s another brain that could be involved. I’m going to imagine — I know an x-ray was done, which was appropriate. The radiologist can help as well, but you need to tell the radiologist enough about the clinical scenario for the radiologist to be of help. So if you had communicated to the radiologist that this was a 55-year-old woman with hemoptysis, tachycardia, marginal oxygen saturation and shoulder pain, the radiologist is able to now do his or her own interpretation, think about the differential diagnosis, things like whether this is pneumonia, whether it’s gallbladder disease, whether it’s a pulmonary embolism. And they could say something in their assessment like, ‘a chest x-ray is not a good way to evaluate for pulmonary embolism. If you’re concerned about it, I think you should do a CT pulmonary angiogram.’ So I think that one mechanism is to leverage the other members of the team.
Another mechanism would be to use some protocols and decision support. For example, if a patient comes in who has an elevated heart rate and a marginal oxygen saturation, trigger the protocol that says think about pulmonary embolism and suggest that to the doctor or the nurse in the triage system or in the clinical decision supporting electronic health record or those sorts of things.
I think there’s another point: A patient returning repeatedly for the same complaint is one of those triggers, so in this case a patient returning three days later and then calling two days later probably should have raised flags that maybe we need to be re-thinking this.
Q.) There was just information sort of in pockets in different places, and it’s really impressive how much this was disjointed, in terms of communication among the different providers. How can we go after that?
A.) It’s a great question, and what you’re seeing in this case is very typical, right? So there are multiple providers involved in the care of the patient. There’s the nurse, the urgent care physician, the primary care physician, plus the radiologist, plus the cardiologist I suppose. Information needs to be conveyed amongst all of those people. One of the things the case did comment on or the case description commented on is the idea that information is gathered, it’s documented, but it’s documented kind of in a temporary format until the clinician can get around to doing the formal documentation in the electronic health record. So the nurse might jot the vital signs down on a piece of paper and maybe they’re not available in the record to the physician at the time of the encounter. The triage might happen but the full triage note might not be available. The physician’s note in the EHR who saw the patient for, in this case I think it was the PCP, and the patient had a consult with cardiology but the PCP’s note wasn’t yet available. So there’s no easy solution to this, but it’s — the availability of that information is just so critical, and it’s often not available.
So I think there’s also the need here to think about ways to capture and convey critical information in very timely ways — you know, automated capture of vital signs that go directly into the EHR that don’t require manual entry, for example, which is the way my clinic does it; to have triage notes available; to have policies and procedures that specify when documentation should be done. So I think it’s a combination of policy and procedure, coupled with measurement and auditing and feedback. But it’s also I think automating things to cut the clinician out of the loop, if you will, as much as possible. Probably all of those things.
Q.) So, Jonathan, when you look at this case does it seem like such an unusual or rare situation, or does it fit more into a pattern of a medical error that you might see resulting from common risks, things that we should look out for?
A.) I think there’s absolutely nothing remarkable about this case. This is very typical, with the possible exception is that the hemoptysis, the coughing up blood, is something that can be seen in pulmonary embolism. But somebody coming in with cough, shortness of breath, maybe a little bit of chest pain. It’s just such a typical visit and most of the time it’s nothing or nothing serious. A couple things here in my opinion should have triggered more scrutiny, and that was really the elevated heart rate and the marginal oxygen saturation. There is the history that was given to the nurse of calf pain and shoulder pain but that almost seems unfair in terms of, man, if the doctor had really understood that part of the history then I can’t imagine how you wouldn’t think of a pulmonary embolism. But no, this is an absolutely typical case.
Q.) And this case was tragic for the family, and you can have some sympathy for the providers as well.
A.) Absolutely, yeah. I guess that’s the part that I look at is, you know, myself and any of my colleagues, we’re always so concerned that we’re going to make a mistake and miss something that we shouldn’t miss and that’s going to result in harm or, in this case, even death of a patient. The fact is, it happens. We’re all human, so I do have a lot of sympathy and empathy for the providers here—clearly a lot of sympathy and empathy for the patient and her family as well. And, you know, again the desire to really put systems in place, you know capital S systems that try to minimize this kind of mistake and not have to rely on the heroic actions of an individual to not make a mistake.
Well, thank you, Jonathan. Dr. Jonathan Einbinder is an internist in primary and urgent care and Vice-President for Advanced Data Analytics and Coding at CRICO. I’m Tom Augello.
About the series
Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.