Critical Opportunity Lost
Commentary by John R. Genzen, MD, PhD, and Heather N. Signorelli, DO
The Case
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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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