Delay in Diagnosis

A challenging area for a Legal Nurse Consultant is the review of cases involving a delay in diagnosis

A delay in diagnosis may lead to an undue patient injury if the illness or injury is allowed to progress rather than being treated. A delay in diagnosis and treatment of an illness or injury may also seriously impact the likelihood of recovery for the patient.

This is best illustrated by the following case. Mrs. Smith, aged 62 years, came to a local emergency department (ED) complaining of chest pain. She was initially evaluated by the triage RN within a few minutes of admission.

Mrs. Smith described her chest pain as severe 10/10 and radiated down her back, arm and neck. Her past medical history was significant for hypertension and she had a long standing history of smoking.

Her BP was recorded by the triage nurse as 230/100. The triage nurse determined Mrs. Smith was an “urgent” category, secondary to the most severe category of “emergent”.

Mrs. Smith was evaluated by the ED physician with 10 minutes of admission. After completing his examination of Mrs. Smith, diagnostic testing was ordered including labs, chest x-ray and ECG as well as placement on a monitor and sublingual nitroglycerin.

Unfortunately because Mrs. Smith was deemed urgent, not emergent, it took over an hour for her to be placed on the monitor and to be given medication. The initial labs, ECG and x-ray were all essentially normal and Mrs. Smith’s BP had improved to 160/80.

After contacting her primary care physician, the decision was made to admit Mrs. Smith for observation and further testing. In addition she was started on anticoagulation therapy.

Later that evening a second ECG showed acute ischemic changes suggestive of an acute inferior wall myocardial infarction. Mrs. Smith was transferred to another hospital because the admitting hospital did not have the capability for heart surgery.

The heart catheterization revealed that Mrs. Smith had an aortic dissection, requiring emergency surgery. At the time of her surgery it was noted she had a large hematoma and hemorrhage around the right coronary artery and right ventricle. Mrs. Smith died shortly thereafter from progressive deterioration.

In reviewing this case it was determined there were several critical delays that ultimately adversely affected Mrs. Smith’s chance for recovery.

The incorrect assessment done by the triage nurse slowed down and delayed her treatment options from the start. The ED physician failed to order the correct diagnostic test, in this case, a CT scan, which also caused a delay in making the correct diagnosis.

The possibility of aortic dissection should have been part of the initial ED differential diagnoses. Mrs. Smith had severe chest, back and arm pain coupled with marked hypertension in a patient with prolonged tobacco use.

If Mrs. Smith had been properly triaged and thoroughly evaluated, emergency surgery would have been performed and more likely than not, would have saved her life.

The take home message in this case is that all patients deserve a complete and thorough evaluation of their complaints. Too often medical professionals stereotype patients (i.e. women less likely to be having heart attacks than men) and miss serious potential problems in which the delay in diagnosis and treatment may mean the difference between life and death.

If you have a case you would like reviewed, please contact me directly.