Reducing missed ACS

  Patients with Acute Coronary Syndrome (ACS) are discharged from the Emergency Department with missed diagnosis at a relatively low rate. But because ACS is a leading cause of death, this translates into a major medico-legal concern for Emergency Physicians. While it is impossible to reduce the miss rate to zero without admitting every patient,…

Prescription for SHIFT work: tips for Emergency Medicine

Ideally, medical care should be provided by a well-rested and nourished provider to one patient at a time through the course of their treatment, with separate time dedicated to teaching. Emergency medicine challenges this concept. The ED consists of shifts around the clock, managing multiple patients without a break but with constant interruptions, where patients…

Missed cauda equina syndrome

Cauda equina syndrome (CES) is an inherently challenging diagnosis to make. It is a needle in a haystack, with back pain being very common but CES being very rare. It carries devastating consequences for the patient and high medico-legal risks for providers. A few weeks ago Steven Chiverton, a 39-year old man, was left paraplegic…

Cellulitis over/underdiagnosis

A patient presents with a red swollen leg. Discharge with oral antibiotics or admit for IV antibiotics? Not so fast.   An recent article highlights the error rate of “cellulitis” diagnoses: Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol 2016 Nov 2, E1-6. In this retrospective cross-sectional study of patients admitted from…

X-ray limitations

Diagnostic errors involving imaging include not ordering appropriate imaging, incorrectly reading imaging, and incorrectly applying the results of diagnostic imaging due to its intrinsic limitations. We can order the right image and correctly read it, but if we don’t consider the inherent test characteristics we can still make a diagnostic error. This especially applies to…

missed stroke

The diagnosis of stroke remains a challenge, due to overlapping symptoms with other conditions, limitations in diagnostic tests, and lack of awareness of posterior circulation presentation and workup. Below is a brief overview of the rate and risk factors for missed stroke, common stroke mimics and chamelons, and the challenge of diagnosing stroke in patients…

missed ACS

Missed ACS is a common source of medico-legal cases. In the Canadian Medical Protective Association’s 2010 article Delay in diagnosis of ACS, they identified 292 ACS related medico-legal cases in the previous decade, and identified common problems: “incomplete history, delay in testing, incomplete testing, and misinterpretation of diagnostic tests.   What’s the scale of the…