What can we learn from medico-legal cases about the most common errors in the Emergency Department?
Two studies of closed malpractice claims from adult patients highlight the importance of misdiagnosis, especially for MI, fraction, infection and appy:
An Epidemiologic Study of Closed Emergency Department Malpractice Claims in a National Database of Physician Malpractice Insurers. Acad Emerg Med 2010;17:553-560. This retrospective review of of more than 11,500 closed claims over 23 years of adult patients in US emergency departments found a number of trends.
- error in diagnosis was the single largest error, and half of claims were attributed to improper/missed diagnosis–followed by improper performance, failure to supervise/monitor, medication error, and failure/delay in referral or admission
- The top misdiagnoses were acute MI, appendicitis, and fractures of the vertebra or long bones.
Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims from 4 Liability Insurers. Ann Emerg Med 2007; 49(2):196-205. This review of 122 closed claims, 65% involved a diagnostic error. These were further analysed:
- missed/delayed diagnosis in descending order: fracture, infection, MI, cancer (these four accounted for half); CVA, embolism, appy
- reason for error, in descending order: failure to order tests, inadequate history/physical, incorrect test interpretation, failure to consult. The majority of misdiagnoses involved more than one error
For pediatric patients:
Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and urgent care centres. Pediatr Emerg Care 2005 Mar;21(3): 165-9. A review of more than 2200 claims:
- 47% of patients were younger than 2
- most common error: diagnostic error
- most common diagnoses: meningitis, appendicitis, arm fracture, testicular torsion
For further reading see my other posts on
- missed appy:
- risk factors: loose stool, pyuria, normal WBC
- missed ACS:
- Risk factors for misdiagnosis included: women less than 55, non-white, shortness of breath, nondiagnostic ECG
- missed rracture:
- pitfalls: insufficient views, inadequate film, non-displaced fracture, little avulsion/big injury, sesamoid vs fracture, second fracture, fracture after hardware