Medical Malpractice Insights: Learning from mistakes and dodging bullets

Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Thanks for allowing me to share excerpts from my free monthly opt-in email newsletter, Medical Malpractice Insights – Learning from Lawsuits. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits.

These posts will appear periodically on for reader enlightenment (and occasionally entertainment).

The first example below is from the September, 2016, issue which highlighted 3 cases of probable negligence that did not result in lawsuits – in the case below, only because the plaintiff (the deceased patient’s wife) died before the case could be filed. Being lucky is no substitute for being smart.

– Chuck Pilcher MD, FACEP, Editor, Med Mal Insights


Learning from mistakes and dodging bullets

When it’s CHF and not “walking pneumonia

Patient dies 20 hours after clinic visit for SOB and chest pain

Facts: An ARNP working in a rural Eastern Washington hospital clinic sees a 69 yo male diabetic, hyperlipidemic smoker who c/o SOB, chest tightness, and fatigue for the past 7 days. Other risk factors include peripheral vascular disease w/ fem-pop bypass, sleep screen-shot-2017-01-15-at-4-51-27-pmapnea, prior TIA, and CVA. He is on an ARB, ACE inhibitor, and Lipitor. Orthopnea is not documented. Exam shows a BP of 98/56 (low compared to prior clinic records) and HR 110 (high compared to prior clinic records.) No temperature is recorded. He also has a moist cough with scattered rhonchi but no wheezing. He is diagnosed with “walking pneumonia” and “SOB,” and is prescribed Augmentin and an Albuterol MDI. A brief differential listed does not include CHF. An x-ray done after leaving the clinic is reported as possible “early CHF.” The x-ray results are called to the patient by an MA and an appointment made for a F/U visit in 7 days. Twelve hours later the patient experiences a cardiac arrest. He is returned to the hospital via EMS and dies. Autopsy reveals coronary atherosclerosis and an MI “about 24 hours old.” An attorney is consulted by the surviving spouse.

Plaintiff: I had multiple risk factors for heart disease and an ACS, but you assumed my problem was related to my smoking. You didn’t address my chest tightness, low BP, or tachycardia. You didn’t even do an EKG because you didn’t consider CHF in your differential. You called it “pneumonia” yet didn’t even take my temperature. Besides, Augmentin is a poor choice for “walking pneumonia,” even if you were right. You didn’t even reconsider your diagnosis after you got the x-ray results, so why did you even bother to order one?

Defense: This case was reviewed prior to filing a lawsuit so no defense position is available.

Result: After review by two experts, the patient’s care was felt to be substandard for an ARNP or other primary care provider in a similar situation. A lawsuit was felt to have merit. However, the plaintiff (the surviving spouse) died before the case could be pursued and the attorney had no other reason to pursue it. A bullet was dodged.

Takeaway: Many steps were missed and assumptions made in this case. Keep an open mind in older patients with chest tightness and SOB.

  • Don’t anchor to one element of history, exemplified by the ARNP’s note that includes this: “As I walked into the room the air was impregnated with stale smoke.”
  • Review x-ray results with an open mind and be willing to reconsider your diagnosis.
  • Compare prior vital signs for significant changes.
  • Have a low threshold for getting an EKG in patients with “chest tightness.”
  • “Scattered rhonchi” are common in CHF.
  • Missing the diagnosis of “Walking pneumonia” is rarely life-threatening. Missing an acute coronary syndrome and/or new onset CHF can be rapidly fatal.
  • In the ED, there are a variety of pneumonia mimics: CHF, PE, aspiration, atelectasis, TB, septic emboli, foreign body, ARDS, and many others. The ED provider must consider and evaluate for these mimics. For more on this, please see this post:


“We learn from failure, not from success.” Bram Stoker, Dracula

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