Performance Improvement - 10 Common Errors

TEN COMMON ERRORS IN EMERGENCY MEDICINE, A RISK MANAGEMENT SUMMARY
Adapted from a lecture by Christine Duranceau, MD, PhD, FACEP

The purpose underlying this summary is to familiarize emergency physicians regarding the following Risk Management objectives:

Identify Potential Areas of Vulnerability

Undertake Specific Preventive Measures

Improve Diagnostic and Therapeutic Accuracy

Promote Patient Satisfaction

1. Missed Fractures – 14% of claims and 17% of total dollars paid
• Orthopedic injuries are the number one cause for lawsuits EM
• Commonly missed orthopedic injuries: closed tendon hand injuries, carpal bone injuries, elbow occult fractures, hip fractures, posterior shoulder dislocations, epiphyseal plate injuries, pubic ramus fractures, patellar tendon ruptures, Lisfranc fractures and compartment syndromes
• Relying on an apparent negative radiograph (many fractures are not readily identifiable initially, i.e., occult fractures)
• Where clinically warranted, maintain a high index of suspicion / when in doubt SPLINT and arrange follow-up SOON
• A reliable radiographic discrepancy call-back procedure is most important
• Be sure to document pertinent communications with the radiologist and patient in the medical record

2. Wound Care – 12% of claims and 8% of total dollars paid
• Failure to identify a retained foreign body in wounds or laceration repairs
• Determine and document the mechanism of injury – maintain a high index of suspicion
• Use imaging techniques liberally – most glass can be seen with plain radiographs; consider fluoroscopy
• Employ good lighting, a bloodless field, wound irrigation, good anesthesia and EXPLORE
• If unable to remove a foreign body, undertake appropriate other specialty consultations
• All wounds must have detailed discharge instructions, including timely and appropriate follow-up

3. Missed Myocardial Infarctions – 10% of claims and 24% of total dollars paid
• Despite increased awareness and advances in diagnostic testing, approximately 2-3% of patients with AMI or unstable angina are discharged home ( up to 11,000 patients per year are sent home)
• AMI is problematic because it has varied presentations
• Failure to diagnose or delays in diagnosis of an AMI is clearly linked to patient injury and disability
• Be especially careful when patients are female, younger than 55 years, are non-white or those patients presenting with non-classic complaints
• Do not rely solely on normal exam and study findings. Be liberal regarding consultation and admission practices

4. Abdominal Pain – 9% of claims and 4% of total dollars pain
• Acute abdominal pain accounts for 5% of all ED visits
• Missed appendicitis and missed ectopic pregnancy represent the majority of claims
• A significant number of claims are misdiagnosed as gastroenteritis – remember for the diagnosis of gastroenteritis the patient must have BOTH vomiting AND diarrhea
• Acute Appendicitis – 65% are non-classic presentations, including normal WBC counts
• High-risk groups include the elderly and children. Do not rely on the urinalysis as it can be abnormal in the presence of acute appendicitis
• Use imaging studies liberally – standard radiographs, and/or CT and/or ultrasound
• If suspicious, consult or admit, or arrange for timely follow-up (6 – 12 hours)

5. Missed Meningitis – 3.5% of claims and 8% of total dollars pain
• Most missed cases involve patients less than 2 years old, as their presentations are often elusive
• Febrile infants less than 2 months should undergo a full septic work-up (CSF, UA, blood cultures)
• Changes in behavior and feeding are important markers in determining whether the infant is “sick”
• If meningitis is suspected – TREAT immediately; do not wait for CSF report

6. Spinal Cord Injury – 3% of claims and 8% of total dollars paid
• The incidence of spinal injury without fracture in adults is low – 0.7%
• Suspect spinal cord injury under the following circumstances:
­Patients complaining of back or neck pain due to trauma
­Facial or head trauma
­Axial load trauma
­Abnormal neurological findings on exam following trauma
­Mechanism of injury
• If patient has altered mental status in the face of trauma – assume spinal injury and undertake appropriate precautions and studies
• One view is no view – obtain minimum 3-view C-spine series and minimum 2-view other spine studies – consider use of CT
• If diagnosis of spinal cord injury – treat according to protocol, including IV methylprednisolone, monitor for spinal shock and/or respiratory distress, especially in high-level cord injury

7. Subarachnoid Hemorrhage/Stroke – 3% of claims and 6% of total dollars paid
• Headaches labeled as migraine can be SAH or stroke
• SAH mortality is high and often presents atypically in young adults
• In all patients with headache consider risk factors, including family history of SAH, connective tissue disorders, hypertension, smoking and alcohol use
• A negative head CT is not always confirmatory. If suspicious perform and LP
• ALL patients presenting with the complaint of a headache must undergo a complete and detailed neurological exam, which must be thoroughly documented

8. Ectopic Pregnancy – 2% of claims and 8% of total dollars paid
• All females of reproductive age with abdominal pain, vaginal bleeding or syncope have an ectopic pregnancy until proven otherwise. At a minimum, obtain a qualitative urine ß-HCG (sensitive to 15 – 50 IU/L, 95% - 100% sensitive)
• If positive, consider a transvaginal ultrasound (greater accuracy than abdominal ultrasound) and a quantitative ß-HCG
• If negative intrauterine pregnancy by ultrasound, then consider ectopic pregnancy
• Do not be misled by tissue that has passed, consider endometrial sloughing in the face of an ectopic pregnancy
• ALWAYS provide for a 24- 48 hour follow-up in all cases, even if reasonably certain of a spontaneous AB or suspect early intrauterine pregnancy
• Consult liberally

9. Poor Documentation
• A well-documented chart is a physician’s best defense in court
• If it is not documented, it wasn’t done
• Document your medical decision logic
• Be careful in the evaluation and treatment of the mentally ill or intoxicated patient

10. Poor Discharge Instructions
• Provide legible discharge instructions, and be specific regarding follow-up, and under what circumstances the patient should return to the ED
• Avoid the use of medical abbreviations in the discharge instructions; PRN, see LMD PRN, take Q4h prn pain, etc. Be specific and not open ended regarding any necessary follow-up
• Whenever possible, include family members in the discharge plan

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