Diagnostic errors occurred in 35 of 100 high-risk cases of patients presenting to the ED with abdominal pain, according to a recent study.1 Researchers developed an electronic tool to identify patients who presented to the ED of an urban academic hospital with acute abdominal pain who were discharged home, had a return ED visit within 10 days, and were admitted to the hospital when they returned.
The researchers identified 100 patients who fell into this category, and found that 35 diagnostic errors occurred during the initial ED visits.
“Many errors fell into a few categories. Remembering these may help physicians avoid the common pitfalls,” says Laura Medford-Davis, MD, the study’s lead author and a Robert Wood Johnson Foundation Clinical Scholar in the Department of Emergency Medicine at the University of Pennsylvania in Philadelphia.
The most frequently missed diagnoses were gallbladder pathology (10 cases) and urinary infections (five cases). More than two-thirds of the cases had breakdowns involving the patient-provider encounter. Most of these involved history-taking or ordering additional tests and/or follow-up and tracking of diagnostic information, such as abnormal test results.
The fact that a large number of errors involved EPs’ failure to address abnormal test results surprised Medford-Davis.
“It seems relatively simple, but providers who made errors often did not mention these abnormal results in their charts,” she says.
One patient had liver enzymes three times the normal level, but it was not mentioned in the ED chart or discharge instructions. The patient was discharged from the ED with an impacted gallstone.
Medford-Davis says EPs should make a habit of reviewing all results one last time before discharge to make sure that they haven’t overlooked anything.
“If there is something abnormal, like liver tests, but the physician still thinks it is appropriate to discharge the patient, they should be sure to document their thought processes,” she says.
It is also important to document a discussion with the patient about the follow-up plan for that abnormality.
In one case, nursing notes for a patient who did not speak English stated that the patient was vomiting so much that she had been unable to keep anything down. The EP’s notes did not document use of an interpreter, and stated “no nausea or vomiting.”
“When the patient returned, those provider and physician notes again documented an inability to tolerate oral intake since onset of symptoms — including during the first ED visit,” Medford-Davis says.
In another case, nursing notes documented right upper quadrant abdominal pain, but the EP’s notes did not.
“The patient was misdiagnosed as kidney stones but the true diagnosis was cholecystitis, consistent with right upper quadrant pain,” Medford-Davis says.
In cases where failure to order the proper test led to errors, usually the missing test was an imaging test.
“This is similar to most malpractice literature, and a frequent cause of litigation,” Medford-Davis notes.
For the study, researchers did not use the legal standard of care, which allows for the consideration of the final diagnosis.
“This allows plaintiff attorneys to argue, for example, that a CT scan should have been ordered that would have diagnosed appendicitis,” Medford-Davis explains.
Researchers relied solely on the symptoms, exam, and results documented during the initial visit to determine if a diagnostic error occurred.
“But even using the more lenient standard, failure to order imaging on a patient with abdominal guarding or grossly abnormal labs and suspicious symptoms still was seen frequently,” Medford-Davis adds.
Researchers also utilized an electronic “trigger algorithm” to identify the 100 high-risk abdominal cases.
“Group practices could adopt this for quality review, to capture and address or learn from many of these high-risk cases in their own practices,” Medford-Davis suggests.
Rush to Diagnosis
EPs must always maintain a high level of suspicion with any abdominal pain patient, warns John Tafuri, MD, FAAEM, regional director of emergency medicine at Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland.
“We see so much abdominal pain; most is a benign process that doesn’t need an acute intervention, but every once in a while the patient needs immediate surgery,” Tafuri says. “That poses medical risks for that patient and legal risks for us.”
Appendicitis cases may be settled for $100,000 or $150,000, he notes, so it may be cheaper to settle than to go to court.
“Abdominal cases are always tough because so much depends on the examination,” Tafuri says. “But you always have to anticipate that you may go to court.”
Tafuri offers some strategies to reduce these risks:
Avoid rushing to a diagnosis of gastroenteritis or stomach flu.
“Patients don’t like to be told that they just have a virus and then have something serious after the fact,” Tafuri says. If the EP conducts a very brief exam and the ED nurse tells that patient they have stomach flu and can go home, “we are right almost every time,” Tafuri says, adding, “but when you are wrong, it gets complicated from a medical/legal standpoint.”
EPs sometimes feel pressure to offer a diagnosis.
“It’s OK to give ‘non-specific abdominal pain’ as a diagnosis,” Tafuri says.
If a malpractice suit occurs, that would be more defensible for the EP than a diagnosis of “stomach flu,” he adds.
Instead, after conducting a thorough evaluation, including a pelvic and rectal exam, EPs can tell patients, “Right now, the tests look OK, but how you feel going forward is more important than the tests and there could still be something serious that did not show up. It’s very important to come back if symptoms worsen or fail to improve so we can reexamine you.”
Tafuri usually provides patients a 12-hour window for this, since most gastrointestinal complaints will improve in that timeframe.
“It plays a lot better with the patient if they do end up with appendicitis,” Tafuri says.
If the patient returns a few hours later and the physical exam is then suggestive of an acute process, Tafuri feels a lawsuit is less likely. This is because the patient wasn’t falsely reassured and was told that it was still possible that a more serious process may be occurring.
“The worst cases are when the patients don’t come back for two or three days, and the ulcer, diverticulitis, or appendicitis is perforated, leading to a much more complicated course,” Tafuri says.
When possible, keep abdominal pain patients in the ED for a period of time and document a second examination.
“I’ve had patients who looked fine when I initially examined them. But by the time I rechecked them a few hours later, after labs and X-rays were back, the exam changed,” Tafuri notes.
Perform and document repeat exams.
“It’s important to document positive findings, but equally important to document negative findings,” Tafuri says.
An EP’s documentation of a benign abdomen during a second examination can be of great help to the defense if the plaintiff attorney later alleges the patient should not have been discharged.
“Documentation of repeat exams shows that you are not blowing off the patient — that the patient was not examined just once but also a second time, just to see if anything changed,” Tafuri says.
Tafuri says the vast majority of abdominal patients will improve and not return to the ED. Good discharge instructions can catch those with an evolving disease process.
“Of the patients that do come back, only a handful won’t have something serious,” Tafuri says.
Medford-Davis L, et al. Diagnostic errors related to acute abdominal pain in the emergency department. Emerg Med J doi:10.1136/emermed-2015-204754.
Laura Medford-Davis, MD, Robert Wood Johnson Foundation Clinical Scholar, Department of Emergency Medicine, University of Pennsylvania, Philadelphia. Phone: (215) 573-2574. Fax: (215) 573- 2742. Email: [email protected]
John Tafuri, MD, FAAEM, Regional Director, TeamHealth Cleveland Clinic. Phone: (216) 476-7312. Fax: (440) 835-3412. Email: [email protected]