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The discoverer of penicillin, Sir Alexander Fleming, warned many decades ago that the “public will demand [the drug and]…then will begin an era…of abuses.” His prophecy has been realized, and I readily confess that I am guilty. During my 37 years in family practice and emergency medicine, I admit that I prescribed antibiotics for viral and self-limited illnesses. There were times when I bowed to pressure from ill and desperate (but not desperately ill) patients or their parents who demanded a cure for an upper respiratory infection.

A 35-year-old female presents at 0321 by ambulance with a complaint of chest pain. The records show EMS arriving at her house and finding the patient on the couch.

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EMT Notes

Patient appears to be anxious and hyperventilating.

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Arriving at the correct diagnosis sometimes follows a short and simple journey.

Consider the classic case of shingles, for example, where the one-step process consists of recognizing the tell-tale pattern of vesicular lesions. Contrast the rash of shingles with the more elusive symptoms of chest pain, headache, or weakness, which usually require a multi-step approach to reach the correct conclusion.

As clinicians, we were all taught the “diagnostic process” in some shape or form. What we didn’t always learn is that each step in the process is accompanied by potential missteps that can take us down the path to misdiagnosis.

The possibility of cyber liability (the threat of liability due to unlawful access to electronic data) has been in the news recently. The reports of security issues include losses by large and small providers. Based on the reports in the media, it would appear that no one is immune to this threat. While there can be no guarantee of immunity, there are things that healthcare providers can do to reduce the threat of loss.

Is there a reliable way to predict which physician will be sued for malpractice? Researchers, insurers and healthcare professionals have wrestled with this question for decades.

A recent study in the New England Journal of Medicine and a follow-up response by the Physician Insurers Association of America (PIAA) provide more data points, but admittedly do not answer the question definitively. Perhaps they are trying to answer the wrong question.

A 78-year-old man, Mr. S, came to the emergency department with the chief complaint of abdominal pain. He was an active person, residing in the independent living section of a retirement complex. He described the pain as an ache in the mid and lower abdomen that had been present for several days. The pain did not radiate. He denied any fever, nausea, vomiting or diarrhea. He claimed having no appetite or bowel movement “for days.”

There is a new risk and safety issue in the world of appendicitis. In this issue of TSG Quarterly, we explore the issue of conservative, antibiotic-first management of acute appendicitis with appendectomy reserved for treatment failures. Is it the new standard? Have you proactively addressed this issue with your emergency medicine and surgical practitioners? It is important to get out in front of this issue to keep our patients safe!

Current strides in improving patient safety in hospitals and medical facilities provide clear evidence that the healthcare industry has the capacity for meaningful change. However, providers continue to face significant obstacles; perhaps the biggest obstacle of all revolves around developing and expanding a vigorous “safety culture.” Indeed, much of the focus has been on technology and incremental process improvement, but building a “culture” is the foundational contributor to ensuring patient safety.

The practice of pediatrics is relatively unique from a risk management perspective. One study placed the risks associated with the practice of pediatrics relative to other specialties as 25^th out of 26 specialties with regard to the risk of being sued. However, although the risk of being sued is relatively low, another study found that the risk that a pediatrician may be sued in a given year was 3.1% as compared with 7.4% for all physicians.

Not all chest pain is a heart attack. While acute coronary syndrome (ACS) may be the most common serious cause of chest pain, clinicians must keep other dangerous conditions in the differential diagnosis and eliminate the possibilities based on the patient’s history, risk stratification, physical exam and diagnostic testing. One of the most dramatic and perplexing causes for acute chest pain, other than ACS, is thoracic aortic dissection.