Repeat Visits Are Second Chances to Avoid Misdiagnosis
By Stacey Kusterbeck
Patients who return to an ED (or visit a different one) for the same complaint are “one of the reddest of flags for adverse events,” warns Michael S. Victoroff, MD, risk management consultant at COPIC, a Denver-based medical liability insurance provider.
Dangerous conditions often missed on the first visit include epidural abscess, posterior circulation stroke, bowel perforation, and infections of the central nervous system and heart. “Conditions that start with subtle signs and evolve over time are traps for the practitioner who is too rushed to let things unfold,” Victoroff says.
Compartment syndromes and other problems involving vascular compromise, testicular/ovarian torsion, and neurological impairments are some conditions EPs miss the first time. Often, these evolving conditions are discovered at the second visit.
Victoroff regularly sees liability claims against EPs for “failure to recognize and rescue,” where the patient’s condition was missed at the first visit. The first EP’s care may be legally defensible if it was reasonable. It also helps if documentation fully explains decision-making.
However, if the second (or third) EP also misses the diagnosis, the care of those EPs becomes harder to defend. Those EPs may be expected to consider the earlier findings from the previous visits. When the second visit happens at the same facility, these findings should be relatively easy for the second EP to see. “When it was a different facility, the provider should try to obtain the earlier records or communicate directly with the previous provider if an evolving serious condition is in the differential,” Victoroff suggests.
Ideally, the second EP checks the vital signs and other objective data at the time of discharge from the initial ED. “Plaintiff attorneys are well aware of the implications of abnormal findings on discharge,” Victoroff warns.
When the plaintiff’s expert reviews the chart retrospectively, it can appear as though the patient was discharged with concerning findings no one acted on. “Retrospectively, we frequently note something in the previous lab or nursing notes that represents a glaring clue to what may not have been appreciated — or may not even have been noteworthy — at the prior visit,” Victoroff says.
Sometimes, it is a matter of what is not in the medical record, such as a detailed neurological exam, a note about peripheral pulses, or an indication of a specialist consultation. Victoroff advises EPs to review their documentation through the eyes of a plaintiff attorney by comparing changes in the patient’s condition and thinking about what might have been missed. This is what the plaintiff attorney will do if there has been an adverse outcome. “The old adage, ‘What’s the worst it could be?’ becomes more relevant when you are dealing with the second presentation of an unresolved symptom,” Victoroff says.
The EP’s goal is to eliminate the most acute, deadly conditions. That is especially difficult in a patient with multiple visits for the same complaint. “This can lead to many different types of biases — specifically, confirmation and anchoring,” explains Daniel LaLonde, MD, medical director of emergency services at Ascension Providence in Southfield, MI.
It is easy to assume a frequent visitor complaining of abdominal pain is presenting again with the same chronic issues. The EP can miss a life-threatening illness (e.g., a ruptured appendix or abdominal aortic dissection). To guard against this possibility, LaLonde treats each visit like it is the patient’s first time. That entails a thorough history and physical and a careful review of documentation from prior visits and workups. “Having a broad but appropriate differential is very important. Risk profiles also depend on the patient’s age and gender,” LaLonde notes.
For example, a young woman may present with an ovarian torsion or a tubo-ovarian abscess. If the patient is an elderly man, consider abdominal aortic aneurysm.
In reviewing ED malpractice claims involving multiple visits for the same complaint, LaLonde has found a pattern of common allegations. These include failure to take a proper history, or a history that conflicts with information documented by other providers.
Often, LaLonde sees failure to order the right diagnostic tests, to obtain a specialty consultation, or to provide the patient with proper discharge instructions. Also, pain medication given in the ED could mask the patient’s symptoms, delaying the diagnosis. The medical record should include several items, including medical decision-making and a thorough review of any information in the record (e.g., imaging, prior visits, surgery consults, outpatient records).
If there was a family member or friend at the bedside, document who was present and who verbalized understanding of the recommendations. If the patient was discharged, include vital signs, fluid tolerance, and abdomen pain levels. Also, indicate these patients received specialist information (if needed), a recommendation to see their primary care physician, and instructions on when to return.
If applicable, note the patient’s history of noncompliance or unwillingness to pursue further workup or management. LaLonde suggests documenting the patient’s own words, such as “I haven’t been to primary care in years,” or “I haven’t gone to any of my follow-ups that you guys suggested.” Those issues should be documented if the EP speaks to another provider to whom the patient was referred. “Most primary care physicians or consultants will tell you if the patient doesn’t follow up or stick to their prescribed regimen,” LaLonde says.
Finally, indicate any issues unique to the patient’s visit. He or she may have visited EDs for chronic abdominal pain. “But maybe this time, the patient was struck in the abdomen, or was involved in a car accident,” LaLonde says.
Conditions that start with subtle signs and evolve over time are traps for the practitioner who is too rushed to let the situation unfold.
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