Delays in care and treatment in the hospital emergency department (ED) and other departments have long contributed to poor patient outcomes and medical malpractice litigation. The Doctors Company's medical malpractice data show continued claims stemming from delays in care.

Case Example

This case involved the death of an adult patient from an alleged failure to timely diagnose and treat a pulmonary embolism (PE) following a six-hour delay in the ED. The patient presented to the ED with complaints of anxiety, shortness of breath, fatigue and body aches. An ED physician triaged the patient but did not document the exam. The ED physician recalled the patient attributed the symptoms to an anxiety attack. The ED physician instructed the patient to return to the waiting room (the ED was understaffed that day) to await further direction.

Nurses monitored the patient's vital signs. Six hours later, when the vital signs worsened, the patient was moved to an exam room and examined by a second ED physician. The second physician noted the patient's medical history included morbid obesity, use of oral contraception, smoking and a family history of deep vein thrombosis. The patient also reported a history of having just returned from a 20-hour drive with no breaks. The second physician ordered a cardiac consultation and an immediate CT scan to rule out a PE. The patient's vital signs deteriorated quickly, however, leading to respiratory arrest. The patient could not be resuscitated. A postmortem examination revealed a massive bilateral PE.

Case Discussion

Experts opined that the patient should have been treated within two hours of the initial ED presentation. Due to the delayed consultation, the cardiologist did not have the opportunity to provide direct patient care; however, the case highlights the continued challenges within EDs to prioritize adequate staffing and comprehensive triage evaluation.

A contributing factor in this event included both understaffed triage staff and ED physicians, perhaps due in part to this having occurred two days before a national holiday. The first ED physician's inadequate patient assessment was a second contributing factor, which resulted in a failure to establish a differential diagnosis and involve cardiology in the management plan.

Risk Management Strategies

• Establish a Pulmonary Embolism Response Team (PERT) program.
  If it is not already established at your hospital, explore the implementation of a PERT protocol with administrators. PERTs provide a multidisciplinary, rapid-response approach to diagnosing and managing PEs. Evidence suggests that PERTs improve patient outcomes by facilitating timely decision-making and personalized treatment strategies, including advanced therapies like catheter-directed thrombolysis. By integrating expertise across specialties, PERTs enhance communication and streamline care pathways, reducing delays and complications. Studies indicate their role in decreasing mortality and hospital length of stay for patients with high-risk PE.
• Use predictive resource allocation to ensure sufficient staffing.
  Insufficient staffing in health care environments leads to higher error rates and increased medical malpractice cases. Research has shown that short-staffed nursing is associated with increased preventable medical errors, complications, patient falls, bedsores, higher hospitalization rates and elevated readmission rates. Additionally, high patient-to-nurse ratios correlate with an increase in medical errors, as well as cases of patient infections, bedsores, pneumonia, cardiac arrest and accidental death. Reduced staffing during weekends and holidays may exacerbate error rates. One study found that patients discharged during a two-week December holiday period had fewer physician follow-up visits and a higher 30-day risk of death or readmission.¹ A similar finding has also been noted on weekend admissions.²
  Partner with organizational leadership and administrators to plan and allocate resources effectively. ED patient volumes exhibit patterns that allow for a degree of predictability, enabling health care facilities to anticipate and manage demand effectively. Studies have demonstrated that forecasting models, such as time series analyses and machine learning algorithms, can predict patient arrivals with reasonable accuracy.^3,4
• Perform thorough patient assessments and document findings.
  The Doctors Company claims data demonstrate that lack of a comprehensive patient assessment, including patient history, is a top contributing factor to diagnostic errors. Document the patient's history, along with your physical findings, treatment plan, and clinical reasoning to support an accurate diagnosis, continuity of care and reduce legal risks.

References

1. Lapointe-Shaw L, Austin PC, Ivers NM, et al. Death and readmissions after hospital discharge during the December holiday period: cohort study. BMJ. 2018;363:k4481. doi:10.1136/bmj.k4481.
2. Cram, P, Hillis SL, Barnett M, Rosenthal GE. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med. 2004;117:151-157. doi:10.1016/j.amjmed.2004.02.035.
3. Hu Y, Cato KD, Chan CW, et al. Use of real-time information to predict future arrivals in the emergency department. Ann Emerg Med. 2023;81:728-737. doi:10.1016/j.annemergmed.2022.11.005.
4. Skinner J, Higbea R, Buer D, Horvath C. Using predictive analytics to align ED staffing resources with patient demand. Healthcare Financial Management Association. January 29, 2018. Accessed Feb. 10, 2025. Available here.

Clinical Topics: Vascular Medicine

Keywords: Cardiology Magazine, ACC Publications, Diagnosis, Differential, Emergency Department, Patient Care, Pulmonary Embolism, Malpractice