■ The healthcare system:

Building safer systems to enhance clinical care delivery

Misdiagnosis in the Emergency Department

Type of activity: Text case

Activity summary

This case describes a fatal outcome for a male emergency patient whose symptoms are mistakenly attributed to intoxication. The facilitation questions and suggestions help learners identify the human factors and cognitive biases that may influence diagnoses in emergency medicine, and determine how the influence of biases can be minimized.

Case scenario

A 32-year-old male is drinking at a bar after midnight and becomes involved in a fight with other patrons. He is struck in the head with a heavy object and is unconscious for 4 minutes. Paramedics bring the patient to the local emergency department (ED) with a large occipital laceration. The paramedic report, which documents the mechanism of injury and the loss of consciousness, is not immediately available to the ED staff due to a transcription delay.

At 02:00, the emergency physician on duty examines the patient and notes that he smells of alcohol and has slurred speech. After persistent questioning, the patient admits to drinking heavily that evening and being in an altercation with another patron. He is unable to recall specific details about how he was injured.  The laceration is sutured, and a procedure note is recorded in the chart. The patient is placed in a hallway to recover until he can be safely discharged. Because the patient is shouting and using foul language, the nurses place him at the end of the hallway so that he will not disturb the other patients.

One hour later, a student nurse examines the patient and documents that he is sleeping and responds only to painful stimuli. She does not notify the emergency physician as she feels that his presentation is consistent with alcohol intoxication. No further orders for on-going monitoring or neurovital signs are requested. The emergency physician does not review the nursing notes or re-examine the patient overnight.

When the patient is re-examined in the morning, he is found to be unresponsive. The patient subsequently dies from an acute intracranial bleed.

Facilitation questions

  1. What human factors led to this patient safety incident (accident in Québec)?
  2. What system factors led to this patient safety incident (accident in Québec)?
  3. What cognitive biases may have affected the decisions of each member of the care team in this case?

Suggestions to faculty

This text case may also be used to explore the CMPA Good practices “Physician-patient: Disclosure of patient safety incidents”“The healthcare system: Human factors” and “The healthcare system: Quality improvement-Patient safety”

CanMEDS: Collaborator, Communicator, Professional

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.