Advanced Practice: "Signs and Symptoms You Would Like to be Sued for Malpractice"

  • "Failure to diagnose" is the #1 reason for malpractice suits against EM physicians


  • If the old mantra that 90% of making a diagnosis comes from the patient history is true, then anything that impairs a good history dramatically increases the chances of diagnostic error


  • Thus, be careful with high risk patients: the elderly, psychiatric patients, intoxicated patients, and non-English speaking patients


  • Bounceback patients: Assume the original diagnosis was incorrect and start over: intensify the workup with labs/imaging as appropriate, consider consultation and admission. Large contract management groups recognize the risk here and many have a "three strikes, you're in!" policy of admitting any patient who presents for a third ED visit without a clear diagnosis.


  • High risk complaints: chest pain, chest pain, chest pain! "Missed MI" still #1 cause of lawsuit for failure to diagnose. Also abdominal pain in the elderly, fever in infants, fever in IV drug use patients, new headache, "pain out of proportion."


  • "Constipation is deadly." Be wary of attributing adbominal pain to constipation. Many inflammatory abdominal emergencies such as appendicitis, diverticulitis, etc may cause a focal ileus and symptoms of "constipation." This diagnosis often appears on the charts of cases that end up as malpractice suits.


  • Poor or cursory consideration of a differential diagnosis: "You miss 100% of the diagnoses you fail to consider."


  • Don't order the wrong test to feel better that you "did something." Ex: CT head in elderly vertigo patients, plain film of the spine in an IVDA patient with back pain. Those tests don't rule out the condition you are worried about!


  • There are plenty more pearls, we will save for a future post!