AHRQ WebM&M: Morbidity and Mortality Rounds on the Web ► Critical Opportunity Lost

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web





Critical Opportunity Lost
After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest. Case review revealed that providers failed to notice the patient had an elevated troponin level prior to discharge. In the accompanying commentary, Jonathan R. Genzen, MD, PHD, and Heather N. Signorelli, DO, both of the University of Utah School of Medicine, discuss critical values and the importance of prompt communication as well as policies and procedures to ensure appropriate care is initiated.

Critical Opportunity Lost

Commentary by John R. Genzen, MD, PhD, and Heather N. Signorelli, DO

The Case

A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the previous night in celebration of her anniversary. She initially attributed her chest pain to acid reflux, but when the pain persisted, she arrived at the ED for further evaluation. During her ED visit, her symptoms resolved with sublingual nitroglycerine and a "GI cocktail" (an oral antacid/anesthetic combination sometimes used to treat possible reflux), and her electrocardiogram was unremarkable. She felt back to "normal" so the clinicians caring for her in an observation unit arranged for a stress test the following morning.

When the patient arrived for her stress test, she reported feeling well with no further chest pain. Approximately 3 minutes into her stress test, she collapsed and went into cardiac arrest. Resuscitation attempts were unsuccessful. The case was reviewed by the hospital's quality committee, whose members noted that the providers in the observation unit failed to note an elevated troponin prior to discharge. The facility recently transitioned to a new electronic health record and questions were raised about how critical or panic lab values should be managed. Providers felt that a lack of such a system had contributed to the error in this patient's care.

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