Patient’s Migraine History Biases Diagnosis in ED

Description

A 41-year-old women presented to the ED with headache, she was treated and discharged within three hours with a diagnosis of migraine. Later the same day she had an acute event. A CT revealed a subarachnoid hemorrhage from a ruptured aneurysm.

Key Lessons

• Each provider owes it to the patient to make an independent assessment.
• Effective bias can narrow a clinician’s judgment and consideration of a patient’s complaints.

Clinical Sequence

A 41-year-old woman with a history of frequent visits to the Emergency Department (ED) arrived there by ambulance with a complaint of headache, nausea, and vomiting. The EMS crew documented that the patient had a headache.

The triage nurse documented that the reason for the visit was a headache, and that the patient was sleepy and “refusing to talk.” While being examined by the Emergency Medicine attending, the patient vomited a small amount of bile. A neurology exam was noted to be within normal limits, however, the record does not include a description of the patient’s headache or other details of her exam.

Within three hours of her arrival, the patient was diagnosed with a migraine. No further testing was ordered. The patient was given Compazine for her nausea, and pain medication.

During discharge, the nurse documented that the patient refused to sit up. She was brought to the waiting room in a wheelchair and discharged to a waiting family member.Later the same day, the patient had an acute event and was taken to another hospital. Imaging identified a subarachnoid hemorrhage from a ruptured aneurysm. The patient had a complicated hospital course and suffered severe permanent cognitive deficits.

Allegation

The patient’s family brought a case against the ED attending physician and two nurses, alleging they breached the standard of care by discharging the patient with an unresolved headache and vomiting.

Disposition

After review, the case was settled in the high range.

Analysis

Risk: The clinical team relied on a working diagnosis of migraine and did not obtain a detailed history, thus missing triggers that may have prompted further evaluation.

Recommendation: A number of factors can influence clinical reasoning including experience, knowledge, and biases. Failure to obtain a thorough history of a patient’s symptoms—or not performing a detailed physical examination—can limit consideration of other potential causes of presenting symptoms. Anchoring on a diagnosis of migraine provided diagnostic momentum; an adequate differential diagnosis was not established. Information that is not consistent with the working diagnosis should prompt reassessment. Develop strategies to reduce reliance on memory; step back and take a cognitive time-out to review information and diagnoses.

Risk: Prior to this encounter, the patient had been treated in the ED with similar complaints. The patient’s family argued that her symptoms were not taken seriously and that a CT or further evaluation was not considered because the team did not consider her complaints to be true.

Recommendation: Clinicians caring for a chronic patients may need to protect against becoming immune to a particular patient’s complaints. In this case, the ambulance crew may have set a tone for the ED visit such that other providers did not explore alternate possibilities for her headache. Organizations trying to raise awareness regarding care of the chronic patient might consider use of diagnostic checklists to assist the care team in checking the completeness of their diagnostic process and expanding differential diagnoses.

Risk: This medical record contained value judgments (“the patient won’t do this”) rather than objective findings.

Recommendation: Documenting contemporaneously at the time of care is critical. A few words is often enough, but whatever is noted should be objective. Subjective comments can give the impression that staff is cynical and uncaring.

Additional Resources

• Massachusetts BoRM Advisory: Diagnostic Process in Inpatient and Emergency Department Settings
• Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims From 4 Liability Insurers
• IOM Report: Improving Diagnosis in Health Care
• Canadian Family Physician: Patient safety and diagnostic error