258 Identifying Medical Error in the Evaluation of Low and Intermediate Risk Chest Pain Patients

Abstract

An ECG is a necessary tool in the evaluation of patients with suspected cardiac disease, although it is rarely diagnostic. We identify a form of medical error in the cardiac evaluation of patients. We performed a retrospective review of patients over the age of 35 receiving a cardiac evaluation in an urban ED from October, 2014 to October, 2015. Patients were identified in 2 cohorts; those with a chief complaint of chest pain (CP cohort) and all others (Atypical cohort) who received a cardiac evaluation (ECG or troponin) during their ED visit. By policy, the CP cohort was mandated to have an ECG ordered at triage. The Atypical cohort had the timing of the ECG left to clinical discretion. Medical error was defined as initiating a cardiac biomarker evaluation without ever obtaining an ECG. In a year, the CP cohort had 4,112 visits, 1,740 patients (42%) had biomarker evaluation, and 6 had a biomarker evaluation without an ECG (0.14% error rate). The Atypical cohort had 29,210 visits with ECG, 12,795 (44%) with biomarker evaluation, and 570 had a biomarker evaluation without an ECG (1.95% error rate), p=0.0001. All medical error in either cohort occurred when the clinician failed to use a chest pain order set. In the CP cohort, the error occurred first in not obtaining an ECG at triage; however, the clinician also failed to use the chest pain order set for evaluation. This data suggests that systematic error can be greatly reduced by the use of standardized CP order sets (in which an ECG is automatically ordered). Although the process error in our sample could be fixed by the use of order sets, measuring and addressing the cognitive error observed is far more difficult. The data calls into question how clinicians are using the ECG in low to intermediate risk CP if they failed to recognize in 2% of the patients that an ECG was never done.