Of 47 unexpected deaths following hospital admission from the ED, half were preventable, according to a recent study.1 The most common process breakdowns were incorrect choice of treatment (47% of patients) and failure to order appropriate diagnostic tests (38% of patients). The most common medical error was a severe delay or absence of recommended treatment for severe sepsis, which occurred in 10 (42%) patients.
The researchers weren’t surprised by the findings.
“Our hypothesis was that the rate of preventable deaths among unexpected deaths was high. Previous studies on unexpected deaths among discharged patients reported a similar rate of preventable death,” notes Yonathan Freund, MD, PhD, one of the study’s authors and an EP at France’s Assistance Publique-Hopitaux de Paris.
Jury Will Be Sympathetic
Any unexpected death that occurs a short time after an ED discharge is bound to get the attention of a plaintiff’s attorney, according to Michael M. Wilson, MD, JD, a Washington, DC-based malpractice attorney. “Anyone is sympathetic to the family of a person, particularly a young breadwinner with children, who is sent home from an ER and then drops dead a few hours later,” he says.
Wilson says the best way for EPs to avoid being a target is to show that they carefully evaluated the person’s complaints, established a reasonable differential diagnosis, and then provided appropriate care with reasonable follow-up.
“Then if the patient dies from an undiagnosed zebra, the ED physician will be able to show reasonable care, and that the unusual disease would not have been diagnosed with standard and ordinary medical care,” Wilson notes.
He explains these practices can mitigate risks for EPs:
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Carefully documenting the history, physical examination, differential diagnosis, and medical decision-making;
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Having a reasonable follow-up plan, documenting that plan, and communicating that plan to the patient orally and in writing;
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Having a physician or nurse document the appearance and status of the patient at the time of leaving the ED, particularly if the time spent in the ED was lengthy;
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Consulting with another EP or a specialist if the ED visit raises questions.
If there are unusual findings, or an unusual event, such as travel to a remote part of the world, “do this even if you think that you know the answer,” Wilson advises.
If a malpractice suit occurs, it will help the EP’s defense to show that the extra effort was made to consult with another physician.
“And, that other physician, be it another ED physician or a subspecialist consultant, can be an extremely valuable witness in the event a lawsuit is filed,” Wilson adds.
These Fact Patterns Are Common
Laura Pimentel, MD, vice president/chief medical officer at Maryland Emergency Medicine Network in Baltimore, MD, is familiar with several malpractice cases against EPs involving unexpected deaths of discharged patients. Here are common fact patterns in these claims:
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Patients with chest pain are evaluated and discharged from the ED, followed by sudden death.
Common allegations in these claims include failure to obtain troponin levels in the ED, failure to properly interpret an EKG showing findings suggestive of ischemia or infarction, and failure to admit a patient for observation or obtain cardiology consultation.
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Patients with subarachnoid hemorrhage (SAH), carotid dissection resulting in stroke, or missed cervical spine fractures are discharged, with missed or delayed diagnosis.
“Neurological cases are particularly difficult, and very high risk for EPs,” Pimentel says.
Missed SAH claims often allege the EP failed to consider the diagnosis and obtain proper diagnostic tests.
“Patients may be mistakenly diagnosed with migraine or other benign etiology for headache, and discharged after symptomatic treatment,” Pimentel notes.
Another common allegation is the patient was discharged after a normal head CT scan was obtained, but the EP failed to perform a lumbar puncture to assess for blood in the cerebrospinal fluid.
“With respect to cervical spine fractures, image with CT scans in patients with concerning mechanisms of injury and those over 40,” Pimentel advises. “It is common for plain radiographs to miss cervical spine fractures.”
Evaluating patients clinically and only ordering a non-contrast head CT is a common pitfall in missed stroke cases against EPs, in Pimentel’s experience.
“Depending upon individual circumstances, patients with suspected stroke should either be admitted for observation and neurology consultation, or evaluated with CT angiography or MRI of the head and neck,” she says.
Cerebellar strokes may be misdiagnosed as peripheral vertigo, with patients mistakenly discharged resulting in death.
“It is incumbent on the EP to obtain proper imaging of the posterior fossa to avoid this fatal pitfall,” Pimentel warns.
In a recent case, an MRI of the cervical spine was ordered for a patient suspected of having an epidural abscess. The study was mistakenly read as normal, and the patient was discharged. He subsequently died of sepsis.
“I am familiar with a disturbing number of cases in which the EP did consider the diagnosis and ordered the appropriate imaging studies, only to have them misinterpreted by the radiologist,” Pimentel notes.
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An EP correctly diagnoses a disease process, such as pneumonia, but misjudges the severity of illness and discharges a patient who subsequently dies.
“The allegation may be that the physician failed to admit and aggressively manage a patient who subsequently develops sepsis or respiratory failure,” Pimentel says.
EPs should utilize clinical decision support tools embedded in most EMRs, such as the pneumonia severity index, Pimentel recommends.
“As this technology continues to improve, one may find that a diagnosis not initially considered is identified by the differential generated by the EMR,” she says. She suggests EPs consider these practices to reduce risks:
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Obtain a consult, observe, or admit patients with concerning but unclear presentations.
“I have found that an order for regular neuro checks on patients with early or subtle neuro complaints in the ED is very helpful in identification of strokes in evolution,” Pimentel says.
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Follow your instincts even if a test result such as an MRI or CT angiography does not confirm your clinical suspicion.
“Strongly consider observation if the patient still looks sick or you are uncomfortable discharging the patient,” she advises.
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Ensure patients and families are comfortable with your disposition.
“Even if the outcome is poor, if the family thought you were diligent and sincere in your management, the likelihood that you will be sued is far lower,” Pimentel says.
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Goulet H, et al. Unexpected death within 72 hours of emergency department visit: Were those deaths preventable? Crit Care 2015;19:154.
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Yonathan Freund, MD, PhD, Emergency Department, Assistance Publique-Hopitaux de Paris, France. E-mail: [email protected].
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Laura Pimentel, MD, Vice President/Chief Medical Officer, Maryland Emergency Medicine Network, Baltimore. E-mail: [email protected].
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Michael M. Wilson, MD, JD, Michael M. Wilson & Associates, Washington, DC. Phone: (202) 223-4488. Fax: (202) 280-1414. E-mail: [email protected].
