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Missed Diagnosis in the ER Leads to Patient’s Death

A fainting spell, preceded by eight hours of chest pain and breathing problems prompted a woman’s husband and son to take her to the emergency room.

But instead of being properly diagnosed with a cardiac condition, she was released about three hours later with a diagnosis of rib pain. Nearly four hours after her discharge she was brought back to the emergency room by ambulance, suffering from tachycardia - a rapid heart beat and heart attack, which resulted in her death.

The 44-year-old woman arrived at the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language.

The patient was first seen by the ED attending physician and then by a resident at 7:50 a.m.. Her initial vital signs were: Heart rate: 107, blood pressure: 146/99, respiratory rate: 29. Her chest pain was documented as "sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation."

The patient's medical history was documented by the resident as: "fainting spells, no family history of coronary artery disease or clots, father suffered a stroke."

At 8 a.m., the patient's initial EKG evidenced changes, which the ED physicians interpreted as non-specific, possibly due to the rapid heart rate. A chest X-ray did not indicate acute cardiopulmonary process. The doctors considered the possible diagnoses of acute costochondritis or inflammation of the rib cartilage, pulmonary embolus or blocked artery in the lungs, and atypical cardiac chest pain. Inexplicably, her doctors did not consider heart attack as a potential diagnosis.

The patient received IV Toradol for pain, which was reduced within an hour. Her blood tests revealed elevated glucose, which was noted as potentially stress-related or non-diagnosed diabetes. At 9:30, a second EKG showed continued tachycardia, HR:103; and improvement of the previous ST wave changes (but still some subtle abnormalities). The ED physicians interpreted the second EKG as reassuring.

At 10:30 a.m., while the patient was still being monitored, the son drove his father to his office so he could make arrangements to be with his wife. When the son returned to the ED at 11 a.m., his mother was being discharged with a diagnosis of rib pain, with instructions to follow up with a physician at a local clinic the next day, or to return to the ED for worsening symptoms.

Her pre-discharge vital signs (documented at 10:15) were: heart rate: 115 and respiratory rate: 28. Her last recorded blood pressure (taken at 8:45 a.m.) was 140/99.

About four hours post-discharge, the patient's family called for an ambulance because of worsening chest pain. The EKG taken en route to the hospital showed signs of reduced blood supply to the heart. Paramedics were unable to detect a blood pressure, and the patient died in the ED.

The patient's estate file suit alleging that the ED resident and attending negligently failed to diagnose and treat the patient's cardiac condition, resulting in her wrongful death. The case was settled for more than $1 million against the attending.

This case had many of the elements of a strong medical malpractice case:

Not following up on abnormal findings: The EKGs were read by the attending and resident before the patient’s discharge. Although the EKG changes were subtle, it was an abnormal EKG in a patient with chest pain. A cardiac consultation was not ordered, and providers failed to order cardiac enzymes to rule out a myocardial infarction heart attack. Doctors could not explain the tachycardia which was still present when the woman was discharged. In addition, the woman was discharged despite the fact that her vital signs were virtually unchanged from the time she arrived at the hospital. In the face of ambiguous findings, the patient should have been admitted to the hospital for observation and a cardiac examination.

Unanswered diagnostic questions: The appropriate tests to rule out a pulmonary embolism or myocardial infarction were not done. This emergency department had no clear chest pain protocol. Protocols for common ED presentations, such as chest pain and abdominal pain, help avoid missed opportunities.

Limited documentation: The last set of vital signs was documented 35 minutes before discharge…and it was incomplete. The last recorded BP was more than two hours old. Even if a patient is on a monitor, it is important to document the vital signs in the chart, especially before discharge.

Poor communication. doctors did not take the possibility of the woman having a heart problem seriously. The diagnostic process and care plan were unclear. After the first series of tests, the son and husband expected that the patient would be in the hospital for a few days.

The decision not to pursue unresolved diagnostic questions made the decision not admit this patient difficult to defend for the hospital. Had the woman’s second episode happened in the hospital while she was on a monitor, she would have had a very good chance of survival.

For more on medical safety issues, see the library of articles by Daytona Beach medical malpractice attorney.





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