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Who’s Next? Patient Safety Risks in Emergency Medicine


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Who’s Next? Patient Safety Risks in Emergency Medicine

By Jock Hoffman, CRICO

Related to: Emergency Medicine

Emergency Medicine providers train to be prepared for whatever comes next without ever knowing who’s next. Nevertheless, multiple caregivers keeping pace with multiple patients are vulnerable to the risk of not having the right information at the right time. Too frequently, those gaps impact clinical judgment and put patients at risk for a missed or delayed diagnosis.

A recent analysis found that eight percent of malpractice cases involved patients seeking treatment in an emergency department (ED). Almost half (47 percent) of the plaintiffs alleged a missed or delayed diagnosis and the majority of those incidents led to permanent injury or death. The average payment for a high-severity case alleging a diagnostic error in the ED was $650,000.1

Emergency Medicine Diagnostic Process of Care

% of Cases* Avg Indemnity
1. Patient notes problem and seeks care 6% $529,000
2. History and physical exam 11% $816,000
3. Ongoing monitoring of clinical status 30% $653,000
4. Ordering diagnostic tests 65% $525,000
5. Performance of diagnostic tests 5% $670,000
6. Interpretation of diagnostic tests 22% $463,000
7. Transmittal of test results
     to (ED) provider
7% $576,000
8. Consultation management 26% $566,000
9. Diagnosis and discharge plan 43% $499,000
10. Post-discharge follow up 
 (includes pending test results)
9% $488,000
11. Patient adherence with follow up 5% $220,000
*Cases may involve breakdowns at multiple points in the process


This table indicates the stages within their ED visits when patients are most vulnerable to diagnostic errors or delays. Analysis of these breakdowns commonly exposes missed opportunities to order appropriate diagnostic tests—or to appreciate the test results and other potentially available information—leading to missed opportunities to initiate an appropriate consult or treatment. With only part of the full picture revealed, an acutely ill patient may be sent home, leaving a more threatening diagnosis looming just out of sight.

While ED patients benefit from added vigilance throughout the diagnostic process, Emergency Medicine leaders may want to focus the bulk of their education and training resources on these four areas in order to minimize diagnostic errors.

Ongoing monitoring of clinical status

  • Establish protocols for recording clinical status (e.g., vital signs)
  • Document response to interventions (e.g., fluids, medications, etc.)
  • Establish structured MD-RN huddles
  • Define specific clinical “triggers” that alert MDs and RNs
    to respond
  • Use a standardized handoff procedures (e.g., SBAR, IPASS)
  • Reassess patient as needed and communicate updates
  • Consider need for additional diagnostic studies

Ordering diagnostic tests

  • Consider atypical presentation and age/gender risk factors, personal/familial risk factors, and peer consultation for repeat visits/unresolved complaints
  • Embed decision-support tools into ED workflow
  • Generate a differential diagnosis regardless of the situation
  • Include all relevant clinical information to assist radiologist, pathologist, etc. in completing the requested test

Consultation management

  • Standardize consult requests and notes; clearly state the reason for the consultation
  • Communicate verbally with consultant at the completion of the evaluation
  • Establish standards for trainee-attending communication for consults
  • Establish standards for response timeliness
  • Establish responsibility for coordinating subsequent care

Diagnosis and discharge plan

  • Huddle for team review (e.g., persistent abnormal vital signs) before establishing the final diagnosis and discharge plan
  • Establish electronic hard stops for critical voids in information before discharge
  • Provide clear, documented instructions for follow-up plan, including communication of outstanding test results
  • Confirm accurate contact information with patient/family
  • Communicate discharge information to patient’s PCP

Without an ongoing relationship with their patients, ED clinicians can be blind to diagnostic errors (perhaps until they are sued for malpractice). Seeking data to better understand patient safety risks can provide more timely knowledge. Exploring opportunities to address the most critical vulnerabilities can turn that knowledge into actions that reduce the risk of harm to whoever shows up next in your ED.

Source: CRICO’s national Comparative Benchmarking System, reflecting approximately 30 percent of closed malpractice cases filed in the United States (N=1,304 ED-related cases out of 15,312 total cases filed from 2006–2010).

Additional Material

Optimizing Physician-Nurse Communication in the Emergency Department: Strategies for Minimizing Diagnosis-related Errors


November 29, 2012
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