Heart Attacks Rarely Misdiagnosed in Emergency Rooms

MedicalResearch.com Interview with:
Daniel A. Waxman, MD, PhD Department of Emergency Medicine David Geffen School of Medicine University of California, Los Angeles RAND Corporation Santa Monica, CaliforniaDaniel A. Waxman, MD, PhD
Department of Emergency Medicine
David Geffen School of Medicine
University of California, Los Angeles
RAND Corporation Santa Monica, California 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: When people talk about medical error, they are usually referring to treatment error—giving the wrong medication, operating on the wrong side of the body, etc.  But many believe that diagnostic error—the failure to diagnose a condition when a patient seeks care—is at least as widespread and consequential a problem.  However, diagnostic errors are intrinsically difficult to measure, since one can rarely prove that a condition was present at the time it was not diagnosed.

In this study, we introduce a novel method for measuring how often patients who come to the emergency room with symptoms of an imminent cardiovascular emergency such as acute myocardial infarction (heart attack) are discharged home without a diagnosis.

We find that among Medicare patients whose ER visits were attributable to symptoms of an imminent infarction, only about 2.3% were discharged home, and that the figure was under 5% for each of the other four conditions we studied.    However, we also found that these relatively low rates did not improve between 2007 and 2014.

 MedicalResearch.com: What should readers take away from your report?

Response: We are doing better than some might have guessed at diagnosing these diseases among Medicare patients when they come to the emergency room.  However, the lack of improvement over a timeframe marked by ever-increasing costs and use of advanced imaging suggests that if we want to do better, we will need to do something qualitatively different from what we have done in the past. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: The ER is but one of many places that patients go for acute medical problems, and our study could and should be extended to consider whether opportunities to diagnose these conditions are missed more frequently when patients present to other care venues such as primary care offices.   It should also be extended to non-Medicare patient populations.

A more daunting task will involve expanding the kernel of our statistical approach to less dramatic but more common diseases and clinical scenarios.   But I hope that before that nut is cracked, the focus will have shifted from measuring the frequency of missed diagnostic opportunities to providing physicians with better tools to not miss them.  The AI revolution will come to Medicine sooner or later!  


Waxman DA, Kanzaria HK, Schriger DL. Unrecognized Cardiovascular Emergencies Among Medicare Patients. JAMA Intern Med. Published online February 26, 2018. doi:10.1001/jamainternmed.2017.8628



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Last Updated on February 26, 2018 by Marie Benz MD FAAD