Clinical Communiqué Volume 5 Issue 2 June 2018
Download PDF: Clinical Communiqué June 2018 Edition
In this edition
Case #1 A TALE OF DISTENSION AND DEPRESSION
Case #2 WELL BETWEEN EPISODES
Case #3 MISSING THE BLEEDING POINT
Expert Commentary REFLECTIONS ON DIAGNOSTIC ERROR – MAKING THE DIAGNOSTIC PROCESS SAFER
Welcome to the June 2018 edition of the Clinical Communiqué. In this edition, we present three cases of patients who died shortly after being assessed and discharged from an emergency department. In each case, an evolving abdominal problem was missed, and the symptoms were attributed to other, less critical causes. Fluctuating signs were misinterpreted, investigative abnormalities were not fully appreciated, and ultimately, diagnoses of life-threatening conditions were missed.
A common mantra in medicine is beware the diagnosis of constipation in the elderly patient with abdominal pain. As two of the cases in this edition highlight, a verse named ‘viral gastro’ could be added to that mantra – beware the diagnosis of viral gastroenteritis in patients with severe abdominal pain and high fevers.
In our December 2014 edition of the Clinical Communiqué, we presented three cases where the lessons to be learned related to clinical deterioration, and the failure to recognise or respond appropriately to early warning signs. There, we looked at heuristic thinking in clinical decision-making. In this edition, we revisit the challenges of clinical decision-making and remember that patients do not always present to hospital with ‘classic’ symptoms and signs for their conditions.
We are very pleased to present two new case summary authors, Dr Guy Sansom and Dr Suzanne Doherty, both emergency physicians, who know only too well the difficulties faced daily by clinicians working in busy emergency departments. Our expert commentary has been written by Dr Carmel Crock, an emergency department director, and the chair of the Australasian College for Emergency Medicine’s Quality subcommittee. Carmel has expertise in incident monitoring and patient safety, and is a founding member of the Society to Improve Diagnosis in Medicine in the USA. She also sits on the editorial board of the journal Diagnosis. Her compelling commentary explores the concept of cognitive bias and the debiasing strategies that can be employed to make the diagnostic process safer. Her recommended resources should be added to every clinician’s reading list to gain an armoury of skills for mitigating diagnostic errors, and gaining a deeper understanding into our work performance.
Another key message from the cases presented in this edition is the importance of incorporating clinical governance systems into hospital processes and patient care. The coroners looked at the environment in which the missed diagnoses occurred, and made recommendations that targeted the systems within which the emergency staff worked. The focus should not be on ‘how do we make sure that an individual does not make that error again’, rather, on ‘how do we all improve and benefit?’
Finally, it is important to remember that while we all need good systems around us to improve patient safety, we cannot be complacent about our individual clinical practice. Humans make errors and systems fail, so we each need internal safeguards in place to prevent adverse events from occurring. We must look within ourselves and strive each day to challenge the veracity and content of our differentials. Reflecting on our cognitive biases and the systems constraints that might have influenced our decision-making, will allow us to be better clinicians for our patients.