Lee Goldman, MD; Ajay J. Kirtane, MD*
*This paper was prepared by Lee Goldman, MD, and Ajay J. Kirtane, MD, for the Quality Grand Rounds Series. Kaveh G. Shojania, MD, prepared the case for presentation. The case and discussion were presented at the 2002 Annual Session of the American College of Physicians in Philadelphia, Pennsylvania, on 1114 April 2002.
Grant Support: Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation as part of its Quality Initiative.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Lee Goldman, MD, Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0120.
Current Author Addresses: Dr. Goldman: Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0120.
Dr. Kirtane: Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215.
Few diagnostic decisions in medicine have been more heavily researched than the approach to the patient with acute chest pain. Despite the advances in both diagnosing and treating patients presenting with this symptom, cases of missed myocardial infarctions still cause substantial morbidity and mortality. This article examines a case in which a patient was sent home from the emergency department after presenting with chest pain and was subsequently found to have a myocardial infarction. In the context of the case, the article discusses clinical decision making about the diagnosis and triage of patients presenting with acute chest pain or with symptoms consistent with possible cardiac ischemia. A standardized approach to addressing the management of these patients is essential, given the adverse consequences of missing a life-threatening condition.
For a list of questions and answers from the Quality Grand Rounds conference, see the Appendix.
Electrocardiograms (ECGs) obtained at presentation and a previous comparison tracing.Top.Bottom.
Receiver-operating characteristic curve of the initial electrocardiographic interpretation.MINew
Table. Recommended Strategies for Determining Where To Admit Patients with Acute Chest Pain for Treatment of Ongoing Life-Threatening Conditions*
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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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.
Cardiology, Coronary Heart Disease, Emergency Medicine.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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