[6 MIN READ]

The overwhelming majority of malpractice lawsuits in emergency medicine and other acute care venues involve the failure to diagnose. In most cases, these patients are discharged home where the missed diagnosis results in an adverse outcome or death. Fortunately, the patient “bounces back” in some cases, creating another opportunity to make the right diagnosis.

Three excellent examples:

1. Spinal epidural abscess is missed on the first visit in 62% of cases, and on average takes 3 or 4 visits to get the correct diagnosis.
2. Acute aortic dissection is missed on the first visit in 28% of cases.
3. Pulmonary embolism is missed on the first visit in 20% of cases.

These numbers are shocking and demonstrate the need for a proactive approach to patient risk and safety.

In many cases, red flags were present and the diagnosis should have been made, but basic elements of the history or physical exam were overlooked. The Sullivan Group (TSG) has analyzed thousands of failure-to-diagnose cases over the decades, and the failure to recognize abnormal—and sometimes very abnormal—vital signs is a common recurring medical error in these cases.

Case History: What’s Wrong with this Picture?

A 37-year-old woman presented to the ED with a cough, chest discomfort and mild dyspnea. She was a smoker but had no medical illnesses. Her only medication was oral contraception.

Her vitals were BP 110/70, pulse 127, respirations 22, temp 99.8°F (37.7°C), and pulse ox 95%. Her lungs were clear; a chest X-ray—PA and lateral—was normal. She was diagnosed with bronchitis and discharged home on an antibiotic.

The next day she became increasingly short of breath and called 911. After EMS arrival, she suffered cardiac arrest and could not be resuscitated.

The autopsy showed multiple pulmonary emboli as the cause of death. A malpractice suit was filed and resulted in a six-figure settlement.

Among the many allegations, the most difficult to defend was the allegation that the patient’s tachycardia (pulse of 127) was an important sign of pulmonary embolus that was ignored by the emergency physician.

Despite the very abnormal pulse rate, the vital signs were not repeated prior to discharge, which was in violation of department policy.

Patients with Very Abnormal Vital Signs: Are You Sending Them Home?

TSG has been evaluating ED risk, safety and quality for 25 years. Discharging patients with abnormal vital signs and getting the team to recognize and re-evaluate abnormal vital signs are common problems. Internal research and the emergency medicine literature indicate that more than 10% of adults are discharged home with an abnormal pulse or respiratory rate, and over 15% of pediatric patients are discharged with at least one abnormal vital sign. Once again, the data is shocking.

TSG recently partnered with d2i to apply our vital sign and other algorithms to d2i’s vast database. d2i provides unparalleled EHR data acquisition and data analytics solutions that aggregate, normalize and curate data from diverse sources, providing actionable insights that optimize emergency department (ED) performance. Together we have been able to provide individual providers with their own performance scorecards regarding the discharge of patients with abnormal vital signs. The answer to the question posed above is: You and your ED team are probably discharging patients with abnormal and very abnormal vital signs.

TSG’s work with hundreds of EDs indicates that a successful approach to medical error and patient safety requires: 1) a solid understanding of ED risk through education; 2) decision support built into the EHR or ambient speech program; and 3) data, more data, and more data that is routinely shared with the entire ED team.

Reviews of hundreds of malpractice cases have shown that tachycardia, particularly when unexplained, is a huge risk factor for adverse outcomes in patients who are discharged from the acute care setting.

Tips to Avoid Vital Sign Errors at the Time of Discharge

• Re-evaluate abnormal vital signs during the patient visit. Especially the heart rate.
• Collect vital sign data and share it with your ED team, both physicians and nurses. You may be shocked!
• Review your nursing policy on re-evaluation of abnormal vital signs. A well-written vital sign policy includes a repeat of vital signs based on time in the ED (e.g., every 2 hours) and a re-evaluation of all abnormal vital signs before discharge. You may be surprised by what is in your policy today!
• Consider further evaluation of patients who remain tachycardic.
• Providers should do a vital sign time-out before discharge on every patient. Many patients present with pain and/or anxiety, which elevate heart and respiratory rates. They typically normalize by the time of discharge. Document that!
• Point out abnormal vital signs during rounding. Have nursing leadership continuously educate regarding this critical issue.