International Journal for Quality in Health Care 15:179 (2003)
© 2003 International Society for Quality in Health Care
Every Defect is a Treasure |
Atypical presentation of myocardial infarction in the outpatient setting, a lapse in clinical knowledge and inadequate data transfer constitute a potentially fatal error
<typesetter: this is to be a 2-column layout, paragraphs in roman type on the left, italic on the right; paragraphs with like numbers should start at the same height on the page, see original enclosed and previous ‘Every Defect’ articles (14/6) for ref.><1>A 64-year-old woman presents to the clinic with complaints of severe mid-back pain, dizziness, and a persistent cough and is examined by an internist covering for her physician. The medical record cannot be located in this busy office practice. Without the benefit of the medical record, the covering internist elicits the medical history from the patient who remarks that she has a history of chronic kidney infections. On examination, the covering internist notes that her pulse is irregular; he orders an electrocardiogram (EKG), blood work, and urinalysis. The internist interprets the EKG and makes notations on a separate piece of paper as to ‘no acute changes’, right bundle branch block, and frequent atrial premature contractions. Basing his judgments on microscopic review of the urine and the patient’s account of kidney problems, the internist prematurely diagnoses a kidney infection and prescribes an antibiotic.
Still experiencing back pain two days later, the patient returns and sees her own physician. A chest X-ray ordered at this visit reveals an area suspicious for pneumonia with a suggestion of congestive heart failure. There is no mention in the medical record of the previous EKG or blood work. Basing his decision on an initial review of the chest X-ray, her physician prescribes a new antibiotic. The next day the patient is seen in the emergency room with progressive shortness of breath and is diagnosed with an extensive acute myocardial infarction complicated by pulmonary edema, liver failure and stroke.
<1>Individuals made errors in the case, but systems and processes conspired to cause the perfect medical storm. No single one of these errors could have caused this adverse event itself. Review of the decision-making processes indicates there was a gap in clinical knowledge regarding the detection of cardiac arrhythmias on EKGs. Given the increased acuity of patients in primary care, providing a refresher course for internists on cardiac arrhythmias may decrease risk, along with establishment of a more reliable mechanism for formal EKG interpretation as back up.
To be sure, the gap in clinical skill combined with an atypical presentation of chest pain and a missing medical record do cause harm. The absence of key patient information places a heavy burden on the busy clinician to obtain an adequate history from the patient, who in this case was not only a poor historian, but also minimized her complaints—she continued working until the late afternoon appointment. In such circumstances, computerized medical records are invaluable for providing easy access to patient information.
<2>On Monday, five days after the initial visit, the patient’s physician returns to his office to find the official readings of the EKG and chest X-ray and the results of the blood work on his desk. The EKG includes changes suggestive of an acute anterior myocardial infarction, the chest X-ray reveals congestive heart failure and the blood work is consistent with an acute myocardial infarction.
<2>This case illustrates the importance of creating systems and processes that are less prone to medical error. Failure to communicate abnormal test results in a timely manner constitutes a potentially fatal error. Once positive results have been obtained, the top priority is to communicate them through effective internal communication systems. Communication on weekends and holidays is a growing concern as evidenced by the case. Early laboratory and radiology response improves patient care; in this case, these two departments had definitive information about these test results, but no direct communication occurred.
To improve the quality of patient care, physician leadership and systems administrators must have an open and vigorous discussion regarding failures to communicate abnormal test results in timely manner, otherwise a ‘culture of low expectations’ develops in which participants expect a norm of flawed exchange of information.
Adapted with permission by Kathleen Dwyer, MS, from Resource, July 2001. Resource is an audiotape publication of the Risk Management Foundation of the Harvard Medical Institutions, Cambridge, MA, USA. 
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