Breakdowns in the initial patient-provider encounter were the most frequent source of diagnostic error in ischemic stroke malpractice cases, according to the authors of a recent analysis.1 Researchers examined 235 medical malpractice claims involving diagnostic error in ischemic stroke patients from 2006 to 2016, using data from the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System database. In 109 of these cases, the diagnostic error originated in the ED. Some key findings:

Failure to assess, communicate, and respond to ongoing symptoms during the ED visit was the source of misdiagnosis in most cases. “Some patients were seen right away, but it still took a while to make the diagnosis of stroke,” says Penny Greenberg, MS, RN, CPPS, one of the study’s authors and a senior program director of patient safety service at CRICO.

Patients exhibited only atypical symptoms in 35.7% of cases. In another 30.6% of cases, patients presented with both traditional and nontraditional symptoms. “Some patients had symptoms of vertigo, but they also had symptoms that could be an evolving stroke,” Greenberg reports.

What follows is a closer look at a few of the cases Greenberg and colleagues examined:

A young woman hit her head while ice skating, with a brief loss of consciousness. The CT was consistent with a concussion, and the patient was admitted for monitoring. She was discharged the next day and instructed to follow up with primary care. No neuro consult was obtained.

An outpatient provider performed a head CT scan, which showed a resolved subarachnoid hemorrhage. The patient returned to the ED with right-sided weakness and slurred speech, and was finally diagnosed with stroke. “The patient requires full-time care, and was unable to return to work as a nurse,” Greenberg notes.

A 61-year-old woman fell at home and reported dizziness. “The family was present with the patient in the ED, but did not provide the EP with additional critical information,” Greenberg says.

The patient complained of headache and nausea after running out of blood pressure medication. “The patient was a poor historian, and had other concerning symptoms that could have been a stroke. But the physician anchored on the patient’s blood pressure, which was very high,” Greenberg notes. The patient was so weak when she was discharged from the ED that she required assistance. “The family was uncomfortable with the discharge. In the morning, the woman returned to the ED and was diagnosed with stroke,” Greenberg explains.

A man with sudden onset slurred speech and left arm weakness was left waiting for two hours after arriving at the ED. By the time the man was finally seen, he was outside the treatment window for tPA.

A young man complained of dizziness and inability to move his right arm and leg. The EP diagnosed right-sided weakness and vertigo, and ordered a head CT scan. An hour later, the patient was discharged with vertigo medication. No stroke workup was conducted, no neurology consult was obtained, and the patient never underwent the CT. “It was unclear who was responsible for ordering the test,” Greenberg says.

When a different EP came on shift, the patient still was complaining of right-sided weakness. After discharge, the patient’s symptoms persisted. He went to another ED, where he was diagnosed with cerebrovascular accident. “The patient suffers from permanent mobility loss and cognitive dysfunction,” Greenberg reports.

Some EDs require that prior to discharge, providers stop to review the final vital signs, test results, and any other pertinent information. “If they had done that in this case, they would realize that the CT had not been done,” Greenberg says.


  1. Liberman AL, Skillings J, Greenberg P, et al. Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database. Diagnosis (Berl) 2019; Jul 11. pii: /j/dx.ahead-of-print/dx-2019-0031/dx-2019-0031.xml. doi: 10.1515/dx-2019-0031. [Epub ahead of print].