Malpractice Counsel

Postpartum Shortness of Breath

A 35-year-old woman presented to the ED after referral by her obstetrician. Six days prior, the patient had given birth to twins without incident. On postpartum hospital day 2, however, she developed mild shortness of breath, and a chest X-ray was ordered. Since there was concern for possible pneumonia, the patient was prescribed oral antibiotics and discharged home on hospital day 4. She continued to complain of shortness of breath following discharge; at that time, the obstetrician referred the patient to the ED for further evaluation.

The patient was evaluated by the EP, who ordered a chest X-ray. He was also concerned that patient had pneumonia and prescribed a different class of antibiotic before discharging the patient home.

One week later, the patient presented back to the same ED with continued shortness of breath. On this visit, she was seen by a physician assistant (PA). Following the history taking and physical examination, a chest X-ray and rapid flu and rapid strep tests were ordered. Both the PA and supervising EP reviewed the chest X-ray and were concerned for pneumonia; however, both the flu and strep tests were negative. A third class of antibiotic was prescribed, and the patient was discharged home.

The chest X-ray on the second ED visit was not interpreted by a radiologist until 3 days later (The patient was seen on a Friday evening and the films were not read until the following Monday morning). The radiologist’s interpretation was “worsening congestive heart failure” (CHF). Two days later (5 days following the second ED visit), the EP was notified of the interpretation discrepancy and made multiple attempts to contact the patient, which included leaving a voice-mail message on her home phone.

The patient returned the call the following day and spoke with one of the ED nurses, who encouraged her to return immediately to the ED. The patient returned to the ED the next day (1 week after her second ED visit) and was admitted to the hospital for CHF secondary to postpartum cardiomyopathy. Unfortunately, she developed an embolus to her kidney, followed by an ischemic cerebrovascular accident, and died 3 weeks after admission.

The patient’s family filed a malpractice lawsuit against the hospital, the EPs, and the PA for negligent delay in making the correct diagnosis, stating that patient’s subsequent stroke and death were a direct result of this delay. Following deliberations, all of the EPs involved in the case were found free of negligence; the PA and the hospital ED, however, were found guilty.

Discussion

Interestingly, the majority of successful malpractice suits against physicians involve cognitive errors and system issues; this case is no exception. Making the correct diagnosis in a patient is a complex process, involving data gathering and synthesis, intuition, clinical experience, and logical thinking. Unfortunately, biases can occur during this process and result in misdiagnosis or delayed diagnosis. These biases include anchoring bias, confirmation bias, premature closure, and diagnosis momentum.¹

Anchoring Bias. This occurs when a physician relies too heavily on the first piece of information or one’s initial impression.¹ Despite evidence to the contrary, the physician keeps returning to the initial diagnosis (ie, he or she is “anchored” to it).

Confirmation Bias. Related to anchoring bias, in confirmation bias, the physician ignores or discounts evidence that contradicts one’s initial impression and focuses solely on the evidence supporting it.¹

Both anchoring bias and confirmation bias appear to have played a role in this case. The differential diagnosis was never broadened beyond pneumonia, despite the fact that one must also consider pulmonary embolism (ie, a hypercoagulable state) and CHF (ie, postpartum cardiomyopathy) in a patient complaining of dyspnea in the postpartum period.

Premature Closure. This occurs when the physician finds a cause that fits the clinical picture and ceases to search for other diagnostic possibilities.^1,2

Diagnosis Momentum. A bias that occurs when the diagnosis considered a possibility by one physician becomes a definitive diagnosis as it is passed from one physician to the next; it then becomes accepted without question by physicians down the line.¹ This type of bias also seems to have played a role in this case.

There are a few strategies to help prevent or minimize these types of errors. First, as new data are gathered, one should reconsider and reprioritize the differential diagnosis. When certain data points do not fit neatly with an earlier diagnosis, careful attention must be paid to them. This is especially true for the patient receiving appropriate treatment but not showing clinical improvement. While it is usually helpful to know previous working diagnoses, the clinician must try to keep an open mind and consider alternative diagnoses. At the end of the day, the lesson is the need to develop a broad differential diagnosis.²