Claims Case Study: Missed Pulmonary Embolism

Failure to diagnose pulmonary embolism (PE) by emergency department physicians is one of the most common sources of ED claims activity. This life-threatening complication is caused by the formation of a blood clot or other mass that becomes lodged in the patient’s pulmonary artery, making it difficult for circulating blood to receive oxygen.

ED physicians should remain on the lookout for symptoms of PE, such as shortness of breath and difficulty breathing. Conclusive diagnosis of PE can be determined by various tests, including chest x-ray, ECG, lung scan, ultrasound, and CT. The larger the embolism, the more harm it can potentially cause, and a substantial clot can result in immediate death. If identified early enough, PE can be treatable with blood thinners over a prolonged period.

When a patient presents with shortness of breath, physicians should also take into consideration certain risk factors that increase the likelihood of PE, including:

• Older age (usually over 60)
• Previous blood clots
• Sitting or lying in bed for prolonged periods
• Cancer
• Fractured leg or hip
• Pregnancy
• Major surgery within the past 3 months
• Smoking
• Taking estrogen replacement or similar medications
• Recent long plane ride

In this study, we examine two missed PE cases that resulted in death, and we offer guidance to prevent this outcome.

Case #1: 38-Year-Old Female

A 38-year-old morbidly obese female who was 10 days post-op from a left salpingectomy and oophorectomy presented to her OB-GYN with complaints of chest pain and vomiting for two days. The patient was tachycardic and diaphoretic. Staff members at the office were unable to auscultate a manual blood pressure reading, and the OB-GYN advised the patient to go directly to the ED. The physician dictated a note for the ED which contained the entry, “I did discuss with the patient that I had concerns that she may be having a PE.”

The patient’s chief complaints at triage were listed as chest pain since the previous night and weakness all over. Initial vital signs showed a HR of 124, RR 20, BP 127/86, and O2 saturation of 96 percent on room air.

She was seen by our insured ED doctor at 6:00 p.m. When interviewed by the physician, the patient complained of nausea and vomiting along with abdominal pain for the prior two or three days. IV fluids, IV Dilaudid and IV Zofran were ordered and administered, and an ECG, CBC, and chest X-ray were ordered. These orders were entered under the physician’s name, but he did not remember or believe that he gave this order, noting that they were likely a standing order set that was activated based on the patient’s initial complaints of chest pain in the triage area. The physician did not review the ECG from the ED, and he did not place any additional orders after his initial assessment. He visited the patient to ask how she was doing, and during each visit, the patient’s primary complaint was nausea/vomiting.

The physician’s shift was over at 8:00 p.m., when his partner took over. The patient never complained of chest pain to the second ED physician, and around midnight, the physician asked her if she was well enough to go home. She stated she was not, so he admitted her for monitoring and evaluation of her continuing nausea and vomiting.

The patient was admitted to an inpatient room at 12:50 a.m. At 4:30 a.m., she was assisted to the toilet. While on the commode, she appeared to experience seizure-like activity and became unresponsive and pulseless. A code was called and was found to be in pulseless electrical activity. Despite aggressive resuscitation efforts, the patient was pronounced dead at 4:49 a.m.

No autopsy was performed. A later review of the patient’s 12-lead ECG that was performed in the ED showed multiple abnormalities that were felt to be indicative of a PE.

Case #2: 45-Year-Old Male

A 45-year-old male presented to the ED complaining of chest pain and shortness of breath, and our insured ED physician managed the patient’s care. The patient reported that he had been diagnosed with a lung mass a few months prior, that he had COPD, and that his cough produced thick, bloody sputum. His primary care physician had previously found the lung mass and had recommended a CT scan, but the patient reported that he could not afford the test. The patient was a one-pack-per-day smoker.

At the time of the exam, the ED physician found no respiratory distress but observed positive crackles with minimal rhonchi. The patient had a coughing spell that resulted in severe shortness of breath with hyperventilation, so the insured prescribed Ativan to help with his anxiety, provided an Albuterol treatment, and began administering IV Decadron. The physician ordered a chest CT without contrast due to a seafood allergy, revealing bilateral infiltrates that indicated pneumonia. The physician ordered cardiac enzyme tests, which revealed slightly elevated troponin levels and increased D-dimer values. According to the patient’s wife, the patient had been drinking alcohol at the time of his ED visit, becoming verbally abusive and combative. The patient attempted to leave the ED against medical advice, but the insured was able to convince him to stay for further evaluation.

The ED physician considered multiple differential diagnoses, including possible PE. He admitted the patient and ultimately diagnosed dyspnea, pleuritic chest pain, and hypoxia. The patient was admitted and given antibiotics, but his condition worsened rapidly, and he was transferred to the ICU under the assumption that he may be suffering from a pulmonary thromboembolus. Lovenox was ordered by the ICU pulmonologist, and the patient coded approximately 1.5 hours later. He was intubated by the insured, mechanically ventilated, given a heparin injection, and started on a heparin drip. The patient regained a heart rhythm for a short period of time, but his condition deteriorated.

The pulmonologist told the family that patient likely suffered a PE and that the only treatment option was to attempt to dissolve the clot with tPA, which was administered over the next two hours. The patient’s condition did not improve, and he remained without any neurological activity. The patient was pronounced dead, and no autopsy was performed. The death certificate listed the cause of death as massive pulmonary embolus with cardiac pulmonary arrest.

What Went Wrong

In the first case, the initial triage notes indicate “chest pain” as a chief complaint, but the patient only related nausea, vomiting, and abdominal pain to our insured physician when asked why she was in the ED; therefore, the physician only focused on those complaints. According to defense experts, the physician would have seen the chest pain complaint if he had read the nurse’s notes or taken a more thorough history from the patient.

In the second case, the primary criticisms against the defending physician were centered around the insured’s failure to adequately consider pulmonary embolism as the primary diagnosis. It was alleged that the patient presented with classic symptoms of pulmonary embolism and that the physician should have ordered a CT scan with contrast, which is not contraindicated in a patient with reported seafood allergy. The physician was also criticized for not ordering a VQ scan or, at a minimum, a heparin drip. The defense countered with expert testimony that the physician had ordered the appropriate tests, requested the appropriate consultations, and had the patient admitted to the ICU, but the specialists were unable to make a timely diagnosis or alter the course of events. The case was tried for six days with a defense verdict for our insured physician.

Risk Management Takeaways:

• Physicians should read all notes included in the patient chart to get a comprehensive understanding of the issues reported and symptoms experienced at each stage of care. Patients do not always include all information each time they are questioned.
• Following a comprehensive review of the notes in the chart, a thorough history and physical exam should take place during the ED physician’s initial encounter with the patient.
• Physicians should know the contents of standing orders in the ED and monitor the results of those orders (e.g., the ECG in case #1).
• If differential diagnoses include PE, appropriate anticoagulation measures should be considered immediately.

For further guidance on this issue, Curi members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.