Monday, October 24, 2011: 4:30 PM
Columbus Hall IJ (Hyatt Regency Chicago)

4:30 PM
Derek Bernstein and Geeta Singhal, Baylor College of Medicine, Houston, TX

Learning objectives: Attendings should listen to trainees carefully. Physicians should not completely accept diagnoses that other physicans make. Physicians should not assume that the laboratory and radiology findings will be normal before checking on the results.

Case information: A 2 month old male with history of an UTI presented to the emergency room with emesis, cloudy urine and concerns of increasing fussiness and poor feeding. He was noted to have poor weight gain and was admitted to the hospital with the diagnoses of failure to thrive and recurrent urinary tract infection. On exam, the medical student reported that the baby was well appearing but with a grade II/VI systolic blowing murmur at the left sternal border.  He mentioned this to the attending who did not confirm the murmur as she focused on how well appearing the baby was and that the diagnosis was a “urinary tract infection.” Urinalysis and urine culture were negative.  A renal ultrasound was normal and VCUG showed bilateral grade III reflux and, incidentally, cardiomegaly.  These results were noted that day by the medical student. The next day, the baby was clammy, diaphoretic and had intermittent perioral cyanosis. The VCUG results were then reviewed by a different attending. A cardiology consult was called and a stat echocardiogram demonstrated TAPVR draining to the coronary sinus and severe right heart dilation.  He was transferred to the CVICU for surgical repair.

Discussion: This case illustrates a number of cognitive errors in diagnosis. The attending accepted the ER diagnosis (premature closure) and despite evidence of a heart murmur, the attending demonstrated “confirmation bias” by not carefully listening to the patient’s murmur. The student demonstrated “blind obedience” in that he noted the heart murmur but did not share the finding with other physicians as the attending was so senior to him.

4:45 PM
Lawrence Mottley, MD, Marie-France Petchy, MD, Philip D. Anderson, MD, Shamai A. Grossman, MD and Jonathan A. Edlow, MD, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

Learning objectives: The use of inappropriate abbreviation can lead to medical errors and harm patients in all fields of medicine

Case information: A 67 year old female with cardiovascular risk factors was referred to the Emergency Department (ED) for chest pain. The patient was initially seen in the office setting, received aspirin, oxygen and nitrates. Physical exam in the ED revealed tachycardia and epigastric pain. EKG showed sinusal tachycardia and diffuse T wave changes. Laboratory tests were significant only for leukocytosis. The patient underwent a CT scan of the abdomen to assess for acute abdominal process. The CT was read as “no acute intraabdominal process but small bilateral PE” on preliminary read. The ED physician interpreted “PE” as “pulmonary embolism”, administered intravenous heparin and admitted the patient to the floor. The next day, she developed gastrointestinal bleeding requiring transfer to the ICU, blood transfusion and emergent endoscopy which showed esophageal necrosis. The final reading of the CT showed no evidence of pulmonary embolism, but did show pleural effusion, which the abbreviation “PE” had been inappropriately used to indicate. “PE” is listed on this institution’s approved abbreviation list as “pulmonary embolism”. The patient was discharged 8 days after admission without further harm.

Discussion: In 2001 the Joint Commission flagged the use of potentially dangerous abbreviations as being a major factor contributing to medication errors. Since then, the standardization of medical abbreviations has been recommended and enforced throughout health care institutions. The use of abbreviations is common in medicine and may lead to serious errors including areas other than medication administration. This case illustrates the impact of inappropriate use of abbreviations on patient safety in the field of diagnostic errors. Reducing the use of abbreviations and/or using only approved abbreviations is a key component for patient safety and health care quality.