When it comes to acceptable miss rates of low-probability, high-risk diagnoses, non-ED providers have a surprisingly low tolerance for risk.1 This finding conflicts with clinical practices observed by study author Eric Chin, MD.

“Based on what we typically see with the consultants we admit to in the hospital, you would think they would be more liberal with their miss rates. But they clearly are not, based on this study,” says Chin, an EP at the San Antonio Military Medical Center.

Researchers had long observed there were different risk tolerances between ED providers and non-ED providers when it came to admitting patients. For instance, EPs tend to want to admit low-risk chest pain patients but face resistance from internists or family medicine physicians who believe the admission is unwarranted.

“The non-ED providers might say that the fact that the chest pain is reproducible is a reason not to admit the patient. But for an ER doctor, reproducible chest pain doesn’t rule out a heart attack,” Chin says.

Researchers wanted to learn more about risk tolerance of providers and patients. They surveyed ED providers, non-ED physicians (including internal medicine, family medicine, and cardiologists), and patients and their family members or close acquaintances. Researchers asked about how much risk they would be willing to tolerate if a family member came to the ED for missed subarachnoid hemorrhage, myocardial infarction, cerebrovascular accident, meningitis, stroke, pulmonary embolism, ectopic pregnancy, or ruptured abdominal aortic aneurysm.

Participants were asked how often they thought it was acceptable for a healthcare provider to miss the diagnosis by selecting one of five percentages: 10%, 5%, 1%, 0.1%, or less than one millionth of 1%.

“Based on the way emergency physicians practice — we are stereotyped as wanting to admit all the low-risk patients — you’d think we’d accept no risk at all,” Chin offers. In fact, ED providers said they would be willing to accept a 1% miss rate for nearly all high-risk diagnoses assessed.

In contrast, says Chin, “the hospital doctors seem to think we want to admit everyone.” The researchers expected to see a risk tolerance that reflected this, but they found the opposite. Non-ED physicians said they would accept only a one-in-a-thousand risk, suggesting they would tolerate a difficult-to-achieve miss rate. To a greater extreme, the same was true of patients and families (they would accept a one-in-a-million risk).

“There is a disconnect here,” Chin says. “The most interesting piece is that EPs know the actual miss rates of ED diagnoses, but most non-ED physicians and patients have no idea.”

This suggests that ED providers, although they know the miss rates, act as though they do not want to miss anything. “ED providers end up admitting people others don’t think should be admitted,” Chin notes.

Fear of litigation is a likely reason. Malpractice outcomes do not always reflect the “acceptable” miss rate for a given condition.

“In the legal climate, if it’s a really sad story or the ED provider is portrayed as uncaring, it’s not uncommon for the jury to side with the patient despite the fact that the standard of care was met,” Chin explains.

Chin says the best way to mitigate these risks is to involve the patient and family member in the decision-making “and show that they made an informed decision and chose, themselves, to take that higher-risk pathway.” According to Chin, ED providers can do this in two ways: by clearly explaining the risks and benefits of hospitalization vs. outpatient management and by documenting the discussion carefully.

Chin offers this example of good documentation: “I discussed with the patient and the family the risk and benefits (to include delay in diagnosis, permanent disability, and death) of evaluating X condition in the ED or hospital. However, the patient declined further evaluation at this time. The patient verbalized a clear understanding, and plans to proceed with an outpatient evaluation and follow-up.”

For patients, the expectation is that ED care “is perfect,” says Chin. “We can’t achieve that, so we have to mitigate the risk.”

(Disclaimer: The view(s) expressed herein are those of the author and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army and Department of Defense, or the U.S. Government.)


  1. Chin EJ, Bloom A, Thompson A. A comparison of perceived acceptable missed diagnosis rates for high-risk emergency medicine diagnoses: A brief report. Am J Emerg Med 2017; 35:1973-1977.