Risk Management Tools & Resources


CASE STUDY: Failure to Diagnose Pulmonary Embolism Results in Patient's Untimely Death

Safety in Numbers: Improving Diagnosis Through Teamwork

Case Details

The patient was a male in his late twenties who suffered from obesity, asthma, high blood pressure, and Crohn's disease. He also had a recent history of surgical repair for a femur fracture. The patient visited his regular family medicine practitioner in October and was treated for rhinitis and sinusitis. His pulse oximetry reading at the time was 99 percent.

A month later, the patient presented to the practice again with complaints of shortness of breath, coughing, and right-sided back pain. At this visit, he saw Dr. M — another family medicine physician in the practice — for the first time. Dr. M ordered a stat chest X-ray, the results of which were negative. The patient's pulse oximetry reading at this visit was 95 percent.

Dr. M diagnosed the patient with bronchitis and prescribed levofloxacin and guaifenesin; she told the patient to return to the office if his symptoms did not subside. One day later, the patient suffered a massive pulmonary embolism (PE) and died. A malpractice lawsuit was filed against Dr. M, which was ultimately settled with a payment in the high range.


A review of this case reveals several risk factors that contributed to the missed diagnosis of PE — the most notable of which is faulty clinical judgment. The term "clinical judgment" refers to the thought process (clinical reasoning) that allows a healthcare provider to arrive at a conclusion (clinical decision-making) based on objective and subjective information about a patient. Because the cognitive processes involved in clinical judgment are complex, they are prone to various cognitive errors. Thus, it is not surprising that clinical judgment is a driving force in diagnostic errors and diagnosis-related malpractice allegations.

In this particular case, two cognitive biases likely occurred — anchoring and availability. Anchoring bias refers to a snap judgment or tendency to diagnose based on the first symptom or lab abnormality. Availability bias can occur if a clinician considers a diagnosis more likely because it is forefront in his/her mind. Past experience and recent, frequent, or prominent cases can all play a role in availability bias. Knowing that the patient had visited the practice just a month earlier, Dr. M honed in on the previous practitioner's assessment and diagnosis of rhinitis and sinusitis. As a result, she "anchored" to this information, maintaining a narrow diagnostic focus that was reinforced by the negative X-ray results.

During litigation, Dr. M was asked why she did not order a CT scan; she stated that she thought the patient should start the new medications to see whether his symptoms resolved. However, retrospectively, case experts agreed that the patient had a deep vein thrombosis (DVT) at the time of the visit as well as signs and symptoms of a PE (i.e., shortness of breath, coughing, and a decreased blood oxygen level). The experts were critical of Dr. M's failure to rule out DVT/PE given the patient's recent surgical femur repair and subsequent inactivity (as well as obesity).

Another risk issue that complicated this case was documentation — both from content and timing perspectives. During litigation, when explaining why she didn't order a CT scan, Dr. M emphasized that the patient was in no acute distress; however, the patient's wife claimed that the patient told Dr. M that he had been coughing up blood, had chest pain, and was sweating. None of these symptoms were noted in the patient's health record.

Further, 2 days after the patient's death, Dr. M amended her documentation from the patient's final visit. The updated documentation stated that the patient did not appear to be in any apparent stress during his office visit, that his shortness of breath occurred only during prolonged coughing spells, and that he denied any chest pain. The timing of this documentation — which occurred after Dr. M became aware of the patient's death — cast doubt on her credibility, and the inconsistencies in her notes made defending the case difficult.

In Summary

Diagnosing patients, particularly patients who have multiple symptoms or conditions, is a complex and challenging process. Although eliminating diagnostic errors entirely is unrealistic, healthcare providers can take proactive steps to improve the diagnostic process, such as taking a thorough medical history, doing a complete physical exam, establishing a differential diagnosis, considering appropriate diagnostic tests and consults, and documenting the patient's care in detail. Further, by identifying and better understanding the factors that contribute to diagnostic errors, providers can implement corrective actions to improve quality of care and reduce liability exposure.

MedPro Twitter


View more on Twitter