So what do we mean by a miss exactly? Is it always a terrible thing and why is it that if we constantly miss diagnoses (we do you know) we are not in court every week? Hopefuly if you have read parts 1 to 5 of risky business then you are now absolutely convinced that error is an integral part of the diagnostic process, in fact it is so much a part of the diagnostic process that I don’t really consider it error any more it is an inevitability that some patients will slip through the diagnostic net when you see them. You will not diagnose them, they will appear to you to be free of disease and you will, no doubt, reassure themselves and yourself that all is fine and dandy. Both you and your patient will hopefully sleep well that night.
Just occasionally though, just once every so often, you will wake about 3am and wonder…., ‘I wonder if that patient was the one that slipped through the net?’, or ‘I wonder if I might call them tomorrow to check they are OK?’ I’ll give a pound to any emergency physician who has never woken with such thoughts, and I’m pretty certain that the pounds will stay in my pocket.
But a miss is a miss isn’t it?
Firstly we should get an idea of what a real miss looks like….., if you are Italian you will not enjoy this!
Now that was a miss with consequences. That miss by Baggio lost Italy the world cup, handing the win to Brazil and pushing Roberto Baggio into top place for world’s worst misses. So it’s a bad one, unlike Diana Ross who also committed one of the worst penalty shots of all time, but there were no consequences at all (except for the obvious humilation)
What do these football analogies tell us as clinician in the ED?
If we don’t ‘make’ a diagnosis what are the potential outcomes for the patient who was missed? The natural assumption amongst most clinicians is that harm will then happen. A missed diagnosis surely means that we have lost the opportunity to make the patient better, but hand on a minute. In the last post we talked about how many therapies (such as thrombolysis) have an inhereny harm within them, so it’s not so clear cut as we might have thought.
So, let’s stop and think about what needs to happen for true patient harm to take place. Perhaps we can think of this as a series of steps. For serious harm to take place a number of things need to happen.
Step 1. The patient needs to get worse.
Pretty obvious if you think about it, but not intuitive. Many conditions that we see in the ED are self limiting, even potentially serious ones such as DVT/PE or even some acute coronary syndromes (depending on your definition) can resolve spontaneously with no long term sequelae. Infections such as pneumonia could go either way but a significant number of patients will get better spontaneously from a whole range of infectious diseases, cardiovascular conditions and trauma.
Step 2. The patient needs to not come back.
Most conditions get worse over a period of hours/days and the patient will develop new or worsening symptoms. Patients with infective disease are classic for this, even when they have significant disease. Almost all other conditions will ‘usually’ worsen, but sadly not all. There is a proportion of patients with conditions such as ACS, PE, SAH where sudden, rapid and fatal deterioration may take place. There is little that can be done in these circumstances, but believe me the incidence of this is rare in comparison to the number of patients we see. So basically, most ‘missed’ patients who get worse will come back.
Step 3. You need to miss it again.
Possible. It is possible to make the same mistake twice. Indeed there is something about our pride as physicians which is challenged by a patient returning with the same problem that we have already ‘ruled out’. Experience has taught me that pride is not a good feature for an emergency physician. Any returning patient should be considered a ‘red flag’. In general terms I teach our juniors that a returns patient is an admit/senior review until proven otherwise. Returns are high risk patients.
Step 4. You have no treatment on return
So, when they do come back for things to get really bad there has to be nothing that we can do to make it better. A patient with a missed MI might come back in cardiac arrest and not survive, which would be awful, but those cases are rare. More commonly a patient will return with a worsening of disease. A missed chest infection may turn to pneumonia, a wound infection to an abscess. Whilst it would have been better for your patient to have been treated at the first opportunity there are still therapeutic options and in the vast majority of cases they will get better.
In other words even if a patient comes to the ED and you do not identify their underlying condition (and if you have read the other posts in this series you will know that this HAS to happen) then it does not mean that disaster will ensue. Most of the time there are either no consequences at all, or, the patient will deteriorate and return within a time frame that gives you opportunity to intervene and treat the condition.
The odds then are very much in your favour, even with the necessity of accepting the fact that we miss diagnoses we can find some solace in the odds that such misses do not lead to disaster. Most patients will safely traverse a number of steps to safely reach the other side of their illness. Does this relax you? Does this make you complacent? Well perhaps. It makes me a little more relaxed about the whole uncertainty of the diagnostic process but I’m not sure that my patients see it that way. Thus far we’ve not really considered the patient, but they must surely feature somewhere and they do…..in Part 7.
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Risky Business Part 7. Risk Proximity
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