CC: CP - How to not get sued!
Catchy title, but there aren’t any ways to actually prevent a lawsuit. You can, however, greatly reduce the chances that a suit goes to trial by carefully documenting what you considered in your work-up and ultimate disposition. That just didn’t fit in the title very well.
“Key process failures were errors in diagnostic assessment, test ordering, and test interpretation. Most often these were attributed to inadequate knowledge, skills, or reasoning, particularly in ‘atypical’ or otherwise subtle case presentations.”
— Diagnostic Errors in the Emergency Department: A Systematic Review. DOI: 10.23970/AHRQEPCCER258
It is not a surprise that “atypical” or “subtle” cases were more likely to be missed - That’s why they are called “atypical” or “subtle”!!! EKG machines can pick up on ST segment changes and EMRs can flag elevated troponins. Soon automation or AI will be applying algorithms like the HEART score and automatically calculating them out for you. What you need to know, is when and what information to feed these risk assessment tools.
That being said, no clinician or system is perfect and some diagnoses are going to be missed. Even if we are able to bring missed myocardial infarctions down to zero with the latest, greatest, highest sensitivity troponin, there are other dangerous diagnoses to consider in the CP patient. Let’s look at the top 5 misdiagnosed condition in the ER, according to this blog post based on above study.
Stroke
Myocardial infarction
Aortic aneurysm and dissection
Spinal cord compression and injury
Venous thromboembolism
If VTE includes PE, then 3 out of the top 5 could present as CP, and only one is “ruled out” by the HEART score. A good clinician needs to have a broad differential diagnosis in undifferentiated CP presentation AND document their clinical reasoning. As an expert witness, I have reviewed cases of devastating missed diagnoses. What is usually on trial, however, is not the error or the miss, but if the clinician failed to meet the standard of care within their medical decision making. It is reasonable not to work up ever dangerous cause of CP, if you show the clinical reasoning for doing so.
