Lessons from an Emergency Room Nightmare

By Harold Pollack, The American Prospect. Posted December 18, 2008.

Emergency physicians face disconcerting challenges that make them especially vulnerable to cognitive error. They must act decisively based on what is currently suspected or known. Doctors and patients both want certainty in an anxious situation. No one is reassured when the doctor says, "I'm not sure what's wrong." Yet those same doctors must remember that their provisional hypotheses might be wrong.

That openness is hard to sustain over the hours and days in which everyone's thinking becomes anchored in a specific diagnosis. The possibility of heart attack was on everyone's mind based on Veronica's dramatic cardiac-enzyme numbers. Had we gone to the hospital first rather than to the urgent-care center, the staff might have conducted a more reflective conversation with Veronica about the specific history of her illness. Given her urgent-care admission, Veronica needed an immediate angiogram before that conversation could really be had. In those first few hours, heart attack was the most reasonable working hypothesis. This deadly possibility needed immediate attention. Yet as economists and psychologists could readily predict, confirmation bias distorted subsequent judgments.

Later, things became murkier. Veronica's arteries and heart tissue looked fine. Her only symptoms were the bad enzyme results and continued chest and arm pain. These were consistent with a heart attack but also with other things. Healthy, 46-year-old women rarely have heart attacks that refuse to leave a trace. That pattern would later pique the curiosity of Veronica's internist. In the moment, hospital staff seemed stuck in a groove created by their own initial treatment plan. Their real mistake was to be incurious once the immediate crisis had passed.

Here's where the need for systemic thinking becomes apparent. When a tired doctor writes an extra zero on his prescription pad or makes a bad initial call, the result can be catastrophic, but it doesn't have to be. Hospitals can be organized to acknowledge the reality that doctors make mistakes and have messy handwriting, and that busy nurses make mistakes, too. As Jerome Groopman knows as a doctor, these mistakes are part of the landscape of medical care.

But Groopman's perspective shows its limitations. He focuses on how clinicians can avoid predictable errors and cognitive distortions. Yet as pediatric cardiologist Darshak Sanghavi notes, diagnostic errors reflect faulty systems as much as they reflect faulty thinking by any one specific person. When we consider how a decent community hospital can improve care, it may be most useful to ask not how doctors think but how systems think.

Writing in The New Yorker, another physician/journalist, Atul Gawande, has noted the value of simple checklists in matters such as controlling hospital infection. Standardization helps individual clinicians to avoid errors. It also forces hospitals and health-care systems to scrutinize their procedures and habits when elements of that checklist are frequently left undone. It's not glamorous, but this is how large organizations improve their performance. One can also create practices and protocols that reduce the likelihood and the probable consequences of common diagnostic errors. Suppose a hospital established a simple rule: Every cardiac patient who reports a recent infection should receive an echocardiogram. Such a rule or a more refined alternative would probably have saved us much time and trouble.

Some things can't be easily replicated. Our internist brought a fresh perspective, distanced from the initial emergency. Equally important, he operated in a hallway culture that encourages questioning and provides backup when things don't add up. He could ask several smart colleagues about what might have been missed. That's a key advantage of academic medicine.

Given my health-policy credentials, I'm embarrassed that I navigated this emergency relatively badly and generally felt no less bewildered than anyone else. I guess the final lessons are more personal. We must forgive ourselves, and others, for our near-misses. Then we must learn from these experiences.

Reprinted with permission from Harold Pollack, "Lessons from the ER," The American Prospect Online: November 23, 2008. www.prospect.org. The American Prospect, 1710 Rhode Island Avenue NW, 12th Floor, Washington, DC 20036. All rights reserved.

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Harold Pollack is an associate professor at the School of Social Service Administration, and faculty chair of the Center for Health Administration Studies at the University of Chicago.

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