Diagnostic errors affect an estimated 12 million people each year in the United States and cause serious harm in an estimated one-third of cases.1,2 Cardiovascular diseases, particularly strokes and myocardial infarctions, have heavy consequences if the diagnosis is missed or delayed.3–5 The major impact of diagnostic errors on public health was highlighted by the National Academy of Medicine's report, Improving Diagnosis in Healthcare, and the report's first recommendation is to “facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families.”2 The report specifically recommends enhancing nursing engagement in the diagnostic process. Nurses are, and always have been, essential to the diagnostic process, and there is an urgent need for the medical world to change the outdated view that diagnosis is solely a provider responsibility. Cardiovascular nurses have tremendous potential to reduce unnecessary cardiovascular deaths from misdiagnoses and lead efforts to address diagnostic errors in both independent and collaborative practices.
The importance of the nurses' role in identifying the signs and symptoms of dangerous cardiovascular diseases and contributing to a correct diagnosis cannot be underestimated.6 To highlight how crucial it is for nurses to own their role in diagnosis, we conducted a review of the Controlled Risk Insurance Company Strategies' repository of malpractice claims, which contains approximately 30% of US claims. This review determined that, in 155 diagnostic error cases from 2007 to 2016, nursing was accused as the primary responsible service. Cardiovascular diseases were involved in 28 of the cases, and more than half of misdiagnoses of cardiovascular diseases (59%) resulted in patient death. A real case of an alleged missed myocardial infarction is described hereinafter to highlight how important it is to educate future and current nurses on their role in diagnosis.
Patient: 81-year-old man with a history of Parkinson's disease, dementia, hypertension, chronic kidney disease, cardiomegaly, and atrial fibrillation.
12:46—Emergency medical service called to the patient's skilled nursing facility. The patient complained of chest pain and abdominal pain.
13:31—The patient arrived at the emergency department with atrial fibrillation, severe chest pain, and mild shortness of breath. Chest x-ray is done and showed unchanged cardiomegaly.
13:45—Electrocardiogram (EKG) shows right bundle branch block and no ST elevations. Troponin level was 0.082 (nondiagnostic). The emergency department physician was concerned for acute coronary syndrome. Nitropaste was applied to the chest and relieved some chest pain. The patient was admitted for observation.
18:41—An internal medicine physician saw the patient who reported that the chest pain improved. The patient had a regular heart rate in sinus rhythm, with no murmurs or thrills. Questionable ST depression was noted. Computed tomographic angiogram showed no pulmonary embolism or aneurysm. The diagnosis was acute coronary syndrome versus costochondritis. Continuing Nitropaste, metoprolol, serial troponins, and serial EKGs was recommended.
20:22—Computer-read EKG showed myocardial infarction. No physician was called by monitor tech to inform of EKG change.
20:55—Laboratory called a nurse to inform of troponin at 57.2 (high). The nurse did not immediately inform any physician.
21:00—The patient complained of increased chest pain.
21:22—Rapid response team called. Hospitalist came to bedside and noted EKG showing 3- to 5-second pauses in heart rate. At this time, the nurse informed the hospitalist of troponin level at 57.2. Serial troponin was drawn again (later came back at 103).
21:29—EKG showed septal Q waves. The hospitalist called an interventional cardiologist at another hospital to arrange emergency transport to their cardiac catheterization laboratory.
22:05—The patient was transferred via emergency medical services. The patient coded in the ambulance en route. The ambulance returned to the first hospital, and resuscitation attempts were made ×30 minutes.
22:44—The patient could not be resuscitated and died. Autopsy showed acute myocardial infarction of the anterior wall of the left ventricle with ventricular free wall rupture.
What Can Cardiovascular Nurse Leaders and Educators Do to Prevent Unnecessary Cardiovascular Deaths From Missed Diagnoses?
How can we best prepare nurses to meaningfully contribute to the diagnostic process and reduce unnecessary cardiovascular deaths? In the case described previously, the guidelines for suspected acute coronary syndrome were followed.7 Serial EKGs were done because the patient was symptomatic after an initial nondiagnostic EKG. Cardiac troponin was measured. Unfortunately, the change in the EKG to an alarming rhythm and high troponin was not communicated to the provider although the nurse was notified. This case highlights that nurses are crucial in the diagnostic process. The importance of nurses' roles in serving as sentinels for our patients, coordinating care, and communicating status changes to other interprofessional team members cannot be underestimated. There are multiple ways nurses can reduce diagnostic error:
- Patient engagement: Nurses already play key roles in patient education and engagement. Understanding patients' major diagnoses, being the advocate of patients as they navigate healthcare, optimizing communication between the patient and the care team, educating about the diagnostic process and diagnostic tests, and helping patients with the emotional burden of not knowing a diagnosis yet or learning of a tough diagnosis are all recommendations from the National Academies of Medicine report.2
- Interprofessional teamwork: Nurses play crucial roles in care coordination and facilitation of team communication. The nurse is often the central team member who must relay critical observations including increased chest pain and troponin levels across professions to ensure rapid intervention. Ensuring that strong teamwork across nurses, physicians, patient care assistants, laboratory technicians, and other allied health professionals applies to diagnosis can go a long way. Preparing future nurses for this major responsibility is important, and the value of teaching communication tools such as Subject, Background, Assessment, and Recommendation is tremendous.Interprofessional education, a requirement by licensing bodies of both physicians and nurses, includes understanding the roles and responsibilities of both professions, engaging in effective communication, and collaborating around shared ethics and values.8 Applying these preexisting requirements to training opportunities related to the diagnostic process and the role of teams in achieving diagnostic accuracy could help prepare both future physicians and nurses.
- Diagnostic triage: Nurses directly engage in a primary component of diagnosis when they triage.6 Whether it is in the emergency department, a home health visit, or a medical surgical floor, nurses constantly make decisions about the level of medical attention needed by the patient. Making this diagnostic triage function explicit could reduce cardiovascular deaths through earlier recognition of clinical red flags for dangerous conditions such as pulmonary embolus and myocardial infarction. Education will be important to increasing nurses' self-efficacy and confidence in their role as diagnostic team members. Educational interventions focused on specific high-risk cardiovascular diagnoses can result in cardiovascular nurses reporting higher knowledge and confidence in assessing and managing the health problem.9
Patients are unnecessarily dying from cardiovascular diseases that were missed on presentation.4 Cardiovascular nurses play an incredibly crucial role in identifying and monitoring signs and symptoms, educating patients, and working with interprofessional team members. It is aligned with the role of the nurses to meaningfully participate in the diagnostic process. Cardiovascular nurse leaders and educators can join the effort to reduce diagnostic errors by training and encouraging nurses to engage their patients in the diagnostic process, to leverage their central role on the interprofessional team to facilitate an efficient and accurate diagnosis, and to acknowledge their existing role in diagnostic triage.
The authors thank CRICO/Risk Management Foundation of the Harvard Medical Institutions.
1. Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med
2. Balogh EP, Miller BT, Ball JR, Error D, Care H, National T. Improving Diagnosis in Health Care [Internet]. National Academies Press; 2015. http://www.nap.edu/catalog/21794
3. Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis (Berl)
4. Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ
7. Amsterdam EA, Wenger NK, Brindis RG, et al. AHA/ACC Guideline for the management of patients with non–ST-elevation acute coronary syndromes. J Am Coll Cardiol
8. Interprofessional Educational Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Interprofessional Educ Collab [Internet]. 2016;10–11. http://www.ncbi.nlm.nih.gov/pubmed/22030650
9. Kirwan CJ, Wright K, Banda P, et al. A nurse-led intervention improves detection and management of AKI in Malawi. J Ren Care