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MissED opportunities

By Jock Hoffman, CRICO

Related to: Communication, Diagnosis, Emergency Medicine, Nursing, Surgery

Missed or delayed diagnoses in the emergency department (ED) are the leading cause of malpractice liability in Emergency Medicine. In a CBS study of 689 ED malpractice cases filed from 2005-2009, more than half (54 percent) alleged a diagnostic error.

While cognitive error on the part of the physician may result in a missed diagnosis, in almost every case reviewed for our study, essential pieces of information were not available to the physician at the time of decision making. This table illustrates, the absence of essential patient information at key points along the process of care for ED patients in diagnosis-related cases.

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*A single case may have errors in more than one step
of the care process
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Typically, the following gaps in key information streams are identified:

  • the availability of prior historical information from the medical record or referring physician;
  • a change in the patient's status or a persistently abnormal vital sign, the timeliness of laboratory or radiology data;
  • communication from the consultant physician; and
  • communication at patient hand offs and discharge.

One area where ED leaders may want to consider improvement is designing structured physician-nurse communication events that facilitate the sharing of critical patient information. Structured communication also helps colleagues convey critical issues in the department (e.g., capacity and patient flow, bed availability). Some specific strategies for structuring MD-RN communication:

Triggers: Set specific physiologic parameters that trigger an alert to both the nurse and physician to respond to an unstable patient (e.g., marked tachycardia/bradycardia, hypotension, increased/decreased respiratory rate, hypoxia, nursing concern).

Physician-Nurse Huddles: Guarantee a time/place to review the patient's course and clarify potential questions. This is particularly important at the time of disposition of the patient, as the decision to admit or discharge often depends on clinical details of which the physician making that decision may not be aware.

Discharge Timeout: Patients are safest when all providers are aware of their treatment plan and all pending issues have been resolved. A coordinated discharge process includes a review of all patient information by both the physician and nurse prior to discharge.

Reconciliation of Abnormal Vital Signs: A frequent theme in medical malpractice cases is the discharge of a patient from the ED with persistently abnormal vital signs. Routine communication of vital signs prior to discharge is an effective way to identify some of these patients in which a potentially serious diagnosis has been missed.

A busy ED provides care for multiple sick, undifferentiated patients at once and providers often work with limited time, information, and resources. Structuring communication between ED physicians and nurses is an effective strategy to address this risk, and avoid having a significant diagnosis missed.

Additional Material

March 1, 2011
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