Lee Goldman, MD; Ajay J. Kirtane, MD*
Goldman L, Kirtane AJ. Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection. Ann Intern Med. 2003;139:987-995. doi: 10.7326/0003-4819-139-12-200312160-00008
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Published: Ann Intern Med. 2003;139(12):987-995.
The ECG shows tracing obtained at initial presentation (and obtained during an episode of chest pain) at half-standard scale. The ECG shows tracing at standard scale from several years before the current presentation. It was available for comparison at the time of presentation, although the difference in ECG standardization was not noted at that time despite the presence of standardization marks. Subsequent recognition of this difference between the 2 tracings presumably contributed to the cardiologist's interpretation of the new ECG as abnormal, with new J-point depression anterolaterally (V to V ).
The cumulative sensitivity (number of patients with myocardial infarction [ ] divided by all patients with MI) of electrocardiographic interpretations is on the y-axis and is plotted against the cumulative false-positive rate (number of patients without MI divided by all patients without MI) on the x-axis. is defined as not known to be old. Reproduced from Rouan et al. .
Dr. M.: I think one of the factors that affected my decision making when I first evaluated the patient was the time of night (2:00 a.m.) and the fact that I had just awakened. I saw her less than a minute after being awakened. What I probably should have done was had her stay in the emergency department, even if I thought she was low risk (which I obviously at that time did), and let more time pass so that my sleep inertia could wear off.
Dr. M.: I told the patient, when she came back about 3 hours later, that she was in fact having an MI, that she probably had been having an MI 3 hours earlier, and that I had misread her ECG. … I apologized to her. She did not think that there was much harm from the 3-hour-or-so delay and was very forgiving. … My junior colleagues were uniformly appreciative of my sharing the error, and they told me it helped create an atmosphere in which they felt more comfortable discussing their own errors. Our chairman was very supportive. He said that he was proud that I had been willing to discuss the error openly and hoped that this kind of disclosure would continue throughout our entire department. I think when we think about systems issues around errors, it is easy enough to say that we shouldn't point fingers at individuals and we should look at the system overall. While I felt that this error was in some ways personal, I don't think of myself as an incompetent physician. Unfortunately, … beyond identifying, in retrospect, that the abnormality in the first ECG was probably underappreciated, I don't think that we, as a group, came up with any solutions. Again, I think the main kinds of solutions could be better training for me or other people in my position, possibly having other providers around who could have evaluated the ECG. But it was hard to come up with a simple solution of how we could prevent this kind of error in the future.
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