Risk Management:

No mistakes for me
Reginald King MBBS MSc DM
Emergency Medicine

Case 1

43 year old male

Vomiting and diarrhea 3 hours after
buying food from street vendor
No fever
Mild cramping abdominal pain
Abdomen soft and non tender
Discharged- Gastroenteritis
Returned 3 days later with peritonitis
Perforated appendix at laparotomy

Case 2
A 25 year old male tried to stop
window from blowing closed
The wound was explored, no foreign
body found and the laceration sutured
2 months later- painful swelling in the
forearm
3cm glass foreign body documented
on Xray and subsequently removed

Case 3

41 year old male

No chronic illnesses
Fit
Epigastric burning after eating
peppery meal
Normal exam
Normal ECG
Discharged as GERD
Died during sleep

Objectives
To give pearls and pitfalls in a few
conditions
To discuss how to minimize the number
of cases that are missed
To discuss how to minimize the impact
on patients of misses
To discuss how not to turn errors into
lawsuits

Appendicitis

Appendicitis
Remains a common cause of litigation
1% of patients with abdominal pain
presenting to ED
3rd most common cause of litigation after
MI and breast cancer

Easy Diagnosis
Referred to by attorneys as a basic
diagnosis
10% false negative rate
18% missed or delayed diagnoses

Graff et al (2000) retrospective study at 12

hospitals with 1026 patients who had
appendectomy

Poor Documentation
1987 Trautlein reviewed 22 cases of
malpractice arising from appendicitis
10 did not document bowel sounds
8 did not document palpation of the
abdomen
12 did not document presence or absence
of rebound
Generally documentation of discharge
instructions and follow- up planning was
inadequate

More CTs the Answer

2714 appendectomies from 1998 to 2004
Rate of scanning increased from 12% in
1998 to 84% in 2004
Led to decrease in complication rate from
33% to 21%
Negative laparotomy rate not significantly
different

Appendicitis is a Clinical Diagnosis

Silen in 20th edition of Copes Early
Diagnosis of the Acute Abdomen
With these tests have come the
unfounded belief that a number or
laboratory report is somehow more
reliable than the clinical history or
physical findings.

Treat the Pain

Does analgesia result in delayed
treatment?
Opiates are safe
Avoid non- steroidals

Frei S (2008). Review of 957 patients with

appendicitis. Case controlled review of 103
missed cases.

Retained Foreign Bodies

Foreign Bodies to the Skin

Wound care is the bread and butter of
Emergency Medicine
Speedy care and high patient
satisfaction
But missed foreign bodies
In top 3 causes of litigation in wound
management

Controversies
Is imaging required?
What is the right imaging modality?
Should it be removed?

Suspect retained foreign bodies

Glass shatters
15% of wounds caused by glass may be
complicated by retained foreign body

Puncture wounds through clothing/

shoes
Bite wounds
Infection occurs
Foreign body sensation
A foreign body has been removed

Examination
A wound that is amenable to examination

Control bleeding
Clean the area
Adequate lighting
Can you see ALL of the wound?

Examination may miss >20% of FB

38% in review of 200 hand foreign bodies

Where wound may be adequately and fully

examined risk of missing FB is low
(2/134) in study by Orlinsky et al (2006)

Is imaging required?

Yes, if
History suggests a potential foreign body
Examination does not rule it out

What about low risk wounds?

Advise patient, review, image if problem
occurs
Image all

The right modality

Xray
Cheap and easily available
Metal 98%, Glass 75%, Wood 7%

HF Ultrasound +/- standoff pad

May be technically difficult
Accurate in experienced hands
Metal 100%, Wood 94%, Glass 92%

False positives

CT/ MRI
Very high cost

Should it be removed
Is it going to cause a problem?
Does the patient want it removed?
Can it be reached reliably without
damaging important structures?
90% can be removed Emergency Physician

Myocardial Infarction

Statistics

USA- Chest pain represents 5% of ED visits

or 5 million patients per year

QEH- 130 patients per month present

with chest pain

It takes 6 to 8 hours to rule out AMI in our

ED

Cost private ED in Barbados- US$300

Consultation, 2 ECGs, 2 bedside quantitative
Troponin

Why is this important?

Wasted
time and
money

Dead
patients
Safety and efficiency of emergency department assessment of chest discomfort
Christenson et al. CMAJ 2004;170(12):1803-7

Myocardial Infarction
The number 1 dollar amount in malpractice
litigation
2-8% of MI missed at initial visit
Fear of litigation in MI affects the emergency
physician in decision making
Katz et al (2005) 33 Emergency Physicians at
2 hospitals caring for 1334 patients with
symptoms suggestive of heart disease

Factors Associated with Litigation

Failure to take and record a careful history

Misinterpretation of the ECG
Failure to recognize atypical presentations
Reluctance to admit patients with vague
or suspicious symptoms
Misguided use of laboratory evidence
Inadequacy of the physicians ED training
and experience

Patient
Characteristics

Physician
Error

Pitfalls in Evaluating the Low-Risk Chest Pain Patient. Jones and

Slovis. Emerg Med Clin N Am 28 (2010) 183201

Complications of Misdiagnosis
Death or potentially fatal
complications within 24 hours in 15%
of admitted patients and 25% of those
misdiagnosed
30 day mortality risk ratio was
doubled in those discharged compared
to admitted patients when controlled
for predicted outcomes
Pope et al (2000) 10689 patients in ACI- TIPI study

Atypical Presentation
Increased risk of misdiagnosis with
atypical presentations
25% of presentations are atypical and up
to 20% of these may be misdiagnosed
Gastrointestinal complaint - 26%
Musculoskeletal pain - 21%

Beware of diagnosing GERD

Could
this
be
AMI?
Up to 29% of patients with AMI will
experience complete pain relief with the
administration of antacids
Antacids and diagnosis in patients with
atypical chest pain
How Useful Are Clinical Features in the Diagnosis of Acute,
Teece,
S., et al,
Emergency
Undifferentiated
ChestJournal
Pain? Goodacreof
et al.
Academic Emergency
Medicine 2002; 9:203208
Medicine
N= 893 20:169, March 2003

Clinical Features that Decrease

Likelihood of AMI

7% of patients with proven AMI

have reproducible chest pain
Emergency Medicine: Avoiding the pitfalls and improving the outcomes. Chapter
1: Harrigan and De Angelis. Editior Mattu.and Goyal. BMJ Books 2007.

Is This Patient Having a Myocardial Infarction? The Rational Clinical

Examination. Panju et al. JAMA Volume 280(14) 14 October 1998 pp 12561263

Young Patients
5% of patients with chest pain secondary to
ACS are under 40
May be related to vasospasm, cocaine,
ecstasy, massive doses of caffeine- Type 2
AMI
Coronary disease other than atherosclerosis
Post undiagnosed Kawasaki disease mean age of
AMI 27 years

Anomalous coronary artery anatomy

Pitfalls in Evaluating the Low-Risk Chest Pain Patient. Jones and
Slovis. Emerg Med Clin N Am 28 (2010) 183201

Women
Women present at
older age usually
and are treated less
aggressively than
men
May present
atypically

Indigestion, tiredness,
palpitations,
weakness
Often misdiagnosed
as panic attacks,
menopause,
costochondritis

Elderly
60% of patients over 85 have no chest
pain on presentation with ACS
Poor historians
Multiple medications
Autonomic neuropathies

Silent MI

Emergency Medicine: Avoiding the pitfalls and improving the outcomes. Chapter
1: Harrigan and De Angelis. Editior Mattu.and Goyal. BMJ Books 2007.

Framingham 25%

N= 5209

GRACE 8.4%
Global Registry of Coronary Events, N>75000

NRMI II- 33% initially pain free on

presentation
National Registry of Myocardial Infarction,
N= 434877
Pitfalls in Evaluating the Low-Risk Chest Pain Patient. Jones and
Slovis. Emerg Med Clin N Am 28 (2010) 183201

Error

Pressures on Physicians to be
always right

Fallacies about error

Only bad doctors make mistakes
We are good doctors
First do no harm
Primum non nocere- Hippocrates

How Doctors Avoid Error in the ED

Read, read, read
Investigate everything
Refer everything
Avoid difficult cases
Get lots of insurance
Read, read, read

The Result- Stress

Errors are Common

Not only are they wrong but physicians are
walking in a fog of misplaced optimism with
regard to their confidence- Lowry
1912 Massachusetts General Hospital clinical
diagnosis wrong 40% of the time at autopsy
Golman et al following autopsies from 1960- 1980
showed a constant misdiagnosis rate
Shojania showed that error rates at autopsy
remained constant at ~23% from the 1960s to
2002

Self Deception
94% of professionals think they are in
the top 50% of their field

Mele AR. Real self deception. Ehav Brain Sci.

1997; 20; 91- 102

How do we make diagnoses?

Patient notices a problem
Physician gathers data
History and physical examination

Makes hypothesis
Confirms or refutes hypothesis
Orders investigation
Interprets results

Sources of Error
Lack of knowledge
Heuristics
Subconscious rule used to make diagnoses/
pattern recognition which bypasses steps in the
cognitive process

All diseases not considered

Premature closure

Data gathered does not support conclusions

made
Confirmation bias

Important information needed for diagnosis

not provided/ collected

Corrections
CME
Recognition of weaknesses
Actively consider alternative
diagnoses and adverse outcomes
Minimize distractions and multitasking

Mitigation
Clear and complete documentation
Detailed discharge instructions
Including how and when patients should
return for follow- up

Feedback and follow- up

Telephone review of patients
Follow- up with colleagues

How to avoid being sued

Be Nice
2/3 claims from patients with no adverse
outcome
3% of patients with adverse outcome sue
70% of litigation is due to poor communication
50% of patients who sue so disliked their
doctor that they wanted to sue before
anything went wrong
No difference in care quality between those
sued often and those never sued
Mastering your risk (2001) Medical Protection Society

Questions?

Clock Tower at the Garrison

Miami Beach

Thank you and Remember.

Be Nice

References
Frei S, Bond W. Appendicitis outcomes with increasing computed tomographic scanning. Am
J Emerg Med (2008) 26, 39- 44
Frei S, Bond W. Is early analgesia associated with delayed treatment of appendicitis? Am J
Emerg Med (2008) 26: 176- 180
Kamin R, Nowicki T. Pearls and pitfalls in the emergency department evaluation of
abdominal pain. Emerg Med Clin N Am 21 (2003), 61- 72
Reynolds S. Missed appendicitis and medical liability. Clin Ped Emerg Med. 4: 231- 234
Silen W. Copes Early Diagnosis of the Acute Abdomen (20 th Ed.). Oxford University Press
2000
Shiels W. Soft tissue foreign bodies: Sonographic diagnosis and therapeutic management.
Ultrasound Clin 2(2007), 669- 681
Levine M, Gorman S. Clinical characteristics and management of wound foreign bodies in
the ED. Am J Emerg Med (2008) 26, 918- 922
Blankenship R, Baker T. Imaging modalities in wounds and superficial skin infections. Emerg
Med Clin N Am 25 (2007), 223- 234
Steele M, Tran L. Retained glass foreign bodies in wounds: predictive value of wound
characteristics, patient perception and wound exploration. Am J Emerg Med (1998)16,
627- 630
Orlinsky M, Bright A. The utility of plain x- rays in all glass caused wounds. Am J Emerg Med
(2006) 24, 233-236
Halaas G. Management of foreign bodies in the skin. Am Fam Physician (2007)76: 683- 688

References

Katz D, Williams G. Emergency physicians fear of malpractice in evaluating patients with

possible acute cardiac ischemia. Ann Emerg Med (2005) 46: 525- 533
Pope J, Auferheide T. Missed diagnoses of acute cardiac ischemia in the emergency
department. N Eng J Med (2000) 342: 1163- 1170
McCullough P, Ayad O. Costs and outcomes for patients admitted with chest pain and
essentially normal electrocardiograms. Clin Cardiol (1998) 21: 22-26
Ghaegammaghami C, Brady W. Pitfalls in the emergency department diagnosis of acute
myocardial infarction. Emeg Med Clin NA (2001) 19 (2): 351- 369
Berger J, Bairey- Merz C.Improving the quality of care for women with cardiovascular
disease: Report of a DCRI Think Tank, March 8 to 9, 2007. Am Heart J (2008) 156: 816- 825
Physician Insurers Association of America. Myocardial infarction study. 1996
Physician Insurers Association of America. Myocardial infarction study. 2000
Physician Insurers Association of America. Myocardial infarction study. 2003
Freas G. Medicolegal aspects of myocardial infarction. Diagnosis and treatment of
myocardial infarction. Emerg Med Clin NA (2001) 19 (2) :511- 521
Sharkey S. Impact of the electrocardiogram on the delivery of thrombolytic therapy for
acute myocardial infarction. Am J Cardiol (1994) 73 (8): 550- 553
Erling B. Disagreement in the interpretation of electrocardiographic ST segment elevation: a
source of error for emergency physicians? Am J Emerg Med (2004) 22: 65- 70
Limkakeng A. Combination of Goldman risk and initial cardiac troponin I for emergency
department chest pain risk stratification. Acad Emerg Med (2001) 8: 696- 702
Duseja R, Feldman J. Missed acute cardiac ischemia in the Ed: limitations of diagnostic
testing. Am J Emerg Med (2004) 22: 219- 225
Sequist T, Bates D. Prediction of missed myocardial infarction among symptomatic
outpatients without coronary heart disease. Am heart J (2005) 149: 74- 81
Schull M, Vermeulen M. the risk of missed diagnosis of acute myocardial infarction
associated with emergency department volume. Ann Emerg Med (2006) 48: 647- 655
Pines J, Szyld D. Risk tolerance for the exclusion of potentially life threatening diseases in
the ED. Am J Emerg Med (2007) 25: 540- 544

References
Mastering your risk. 2001. Medical Protection Society
Kachalia A, Gandhi T. Missed and delayed diagnoses in the emergency department: A study of closed
malpractice claims from 4 liability insurers. Ann Emerg Med (2007) 49: 196- 205
Goldberg R, Kuhn G. Coping with medical mistakes and errors in judgment. Ann Emerg Med (2002) 39:
287- 292
Davenport J. Documenting high- risk cases to avoid malpractice liability. Youre at the highest risk of
malpractice suits when dealing with these five clinical conditions. Full documentation can help. Fam Pract
Manag (2000) 7 (9): 33- 36
Chern C, How C. Decreasing clinically significant adverse using feedback to emergency physicians of
telephone follow- up outcomes. Ann Emerg Med (2005) 45: 15- 23
Berner E, Graber M. Overconfidence as a cause of diagnostic error in medicine. Am J Med (2008) Vol 121
(5A), S2- S23
Schiff G. Minimizing diagnostic error: the importance of follow- up and feedback. Am J Med (2008) 121 (5A)
: S38- S42