Blog & Articles

In emergency medicine and presumably in urgent and primary care, one of the common failure-to-diagnose drivers is the failure to recognize or act upon abnormal vital signs. In one analysis of 90,000 patients that we published in Annals of Emergency Medicine, 16% of patients presented to the emergency department with an abnormal vital sign, and 10% of that group went home without a single repeat of the abnormal vital sign. That analysis came from over 200 emergency departments across the U.S., representing over 7 million patient visits annually. From a quick calculation, you can see there are a lot of patients with abnormal vital signs being discharged from EDs across the U.S., and there are undoubtedly failure-to-diagnose adverse events and significant morbidity in that patient group.

Acute ischemic stroke affects about 800,000 patients a year in the U.S.; 600,000 of these cases are a first stroke. Stroke is a leading cause of permanent cognitive and function-limiting disability, and it ranks fifth among all causes of death. Prompt recognition of an acute ischemic stroke is crucial, as studies show that the volume of irreversibly damaged brain tissue expands rapidly until reperfusion occurs. The American Heart Association guidelines call for rapidly recognizing a neurological deficit, ruling out the mimics of a stroke, and making the early diagnosis of stroke.

The Maternal Fetal Triage Index (MFTI) tool developed by obstetric experts at AWHONN is a recent advance that deserves attention from all obstetric professionals. If you haven’t yet learned of it, stay tuned, because you will be hearing much about it as it goes “live” in the EMR of many institutions around the country.

Practitioners should employ Evidence-Based Medicine or Best Evidence whenever possible. No one would argue with that. If a patient presenting with chest pain has a very low probability of a pulmonary embolism based on good evidence, it would be inappropriate to order a CT scan and expose a patient to the dangers of unnecessary radiation. Alternatively, if an algorithm suggests that pulmonary embolism is likely or probable, it would be inappropriate to “fail to order” a CT scan of the chest.

Accurate triage of patients in an emergency department is critical to timely care and patient safety. 

Read these four clinical tips for triage nurses based on recent trends spotted by RSQ® Collaborative Triage Champion, Shelley Cohen, RN, MSN, CEN. 

Download these tips as a PDF.

In order to provide the highest quality and safest care, medical practitioners should have immediate access to clinical decision support. Medicine should not be a memory game; in fact, according to an analysis by Allan Kachalia, MD, JD, published in the Annals of Emergency Medicine, relying solely on memory could leave you more susceptible to cognitive errors that lead to malpractice claims. Kachalia’s closed claims analysis found that cognitive errors were present in 96% of the cases; furthermore, 58% and 41% of the time, those errors were related to gaps in knowledge and lapse in memory, respectively. It is simply not possible to remember all of the information needed to diagnose a patient, such as the factors that predispose to a pulmonary embolism or a subarachnoid hemorrhage; all the elements of the Modified Wells or PERC calculators; all the key tendons and ligaments in the body; all the names of the bones in the ankle and the wrist; or all the cranial nerves and exactly what they do. But these are key data points — risk factors or anatomy that MUST become front of mind at just the correct moment during a particular patient’s workflow to provide appropriate care and avoid error.

Imagine this scenario: You have been following this 22-year-old primigravida patient since she transferred into your practice at 18 weeks gestation. She tells you that she started her pregnancy weighing 195 pounds; it is now two weeks before her due date and she weighs 248 pounds. 

She failed her 28-week glucose screen; after the 3-hour oral glucose tolerance test, she was diagnosed as being a gestational diabetic. Despite referrals to a dietitian and to the Diabetes Clinic, her blood sugar control and dietary compliance have not been good. At her prenatal visit last week, her fundal height was measured at 43 cm.

Every healthcare professional is familiar with the traditional learning methods of classroom lectures, texts, conferences and hands-on clinical training. For “experienced” older clinicians (like me) educated during the pre-internet era, these were the exclusive methods employed during college, medical/nursing school, internship, residency and beyond. You went to lectures, hit the books, and relied on the “watch one, do one, teach one” process of mastering new procedures.

In a previous article entitled “Should Your EHR Documentation Templates Include Chief Complaint Specific Content,” we emphasized the importance of providing chief compliant-specific content in physician documentation templates for medical specialties that are susceptible to diagnosis-related errors. Let’s advance that concept a step further and explore what other features could be built into an EMR to increase compliance with the key drivers of clinical decision-making in the history and physical exam. For example, would it make a positive impact on patient safety if certain clinical elements in the template were highlighted to draw a greater level of awareness and compliance? For the sake of this discussion, call that “Guidance.” What does that look like? The image below is an example of what Guidance looks like in a new physician documentation application called Medical Professor™. 

Electronic Medical Record (EMR) and Electronic Health Record (EHR) systems were developed to satisfy several important needs (I will use EMR and EHR interchangeably). Just to name a few: legible documentation of patient encounters, satisfaction of coding and billing requirements, regulatory compliance, prevention of medication errors, clinical pathway utilization, medical-legal defensibility, and data compilation. Having seen and used several EMR systems, I can tell you that they were not developed with the primary goal of improving user efficiency.