Missed diagnoses in patients admitted from the Emergency Department

misdiagnosed

There are patterns diagnoses for patients discharged from the Emergency Department whose were deemed well enough for discharge and whose diagnoses were missed (MI dismissed as GERD, fracture missed on Xray, appy misdiagnosed as gastro). But there are other patterns of diagnoses for patients who are deemed sick enough to require hospitalization, but the reason is misdiagnosed.

Evaluation of Missed Diagnoses for Patients Admitted from the Emergency Department. Acad Emerg Med 2001 Feb;8(2): 125-130. This study found a very low rate of misdiagnosis (<1%) but with some important lessons–comparing admission diagnosis with discharge diagnosis:

  • abdo pain –> GI bleed
  • back pain –> myeloma
  • CHF –> pneumonia
  • chest pain r/o MI –> Gi bleed
  • chest pain r/o MI –> dissection
  • chest pain r/o MI –> GI bleed
  • chest pain r/o MI –> CHF, dig toxic
  • chest pain r/o MI –> GI bleed
  • COPD –> pneumonia
  • confusion –> hypocalcemia
  • dehydration, ARF –> dig toxic
  • dizzy –> GI bleed
  • elbow/face abrasion –> r/o cardiac contusion
  • gastro –> pancreatitis
  • hypotension –> urosepsis
  • mental status changes –> PE
  • pelvic fracture –> bronchogenic carcinoma
  • pulmonary edema –> AF
  • facial lac –> pneumothorax
  • SOB –> CHF, anemia, leukemia
  • vomiting –> pancreatitis
  • weak –> GI bleed
  • weak –> pneumonia

Emergency Medicine diagnoses can be categorized by body system, and within this by diagnosis–and I’ve create mnemonics for each of these in the “Integrated approach” section of this website: Airway (ABCDEFGHIJKLMNOP), B(CHEST), C (CARDIOVASCULAR), D (NEUROLOGIC), E(ENDO), Fluids/Fertility(CREATININE/PELVIS), GI(ABDOMINAL), H(HEME-ONC), I (INTOX), J(joint, skin, bones).

Most emergency medicine diagnostic errors fall into two categories

#1) diagnosing the wrong body system: confusion diagnosed as neurological (D system) instead of C(eg PE) or E (eg hypocalcemia); trauma or back pain diagnosed as MSK (J system) instead of heme-onc (H system); SOB diagnosed as CHF (C system) instead of pneumonia (B system)

#2) diagnosing the right body system but the wrong condition within this system: dissection or GI bleed diagnosed as MI (all within the Cardiovascular system).

To avoid some of these errors in common chief complaints:

  1. weak/dizzy
    1. consider B (pneumonia), C (GI bleed)
  2. fall
    1. before jumping to the obvious facial/elbow abraisions (J), consider B (pneumo) and C (contusion) injuries
    2. within fractures (J), consider pathological fractures
  3. chest pain
    1. consider differential and interconections of CARDIOVASCULAR system, eg Outflow dissection, Abdominal bleed–especially before anti-coagulation –> rectal exam
  4. SOB
    1. consider broad differential for SOB, including C (CHF, AF), H (anemia, leukemia)
    2. consider alternatives or co-existing diagnoses within the CHEST system
      1. eg in COPD or pulmonary edema, consider pneumonia
  5. altered
    1. consider broad differential: C(PE), E(calcium), I(dig)
  6. abdo pain
    1. before jumping to the G system consider CARDIOVASCULAR, eg GI bleed
    2. before diagnosing gastro consider worse ABDOMINAL within the GI system, eg pancreatitis, appy

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