Medical error – Missed MI

 You are the medical FY 2 on the cardiology ward.

 35 years old Mr Michael was admitted with a chest pain 3 days ago and was
treated for Acute inferior myocardial infarction. Now he is stable on medical
therapy.

 On looking at his notes, you noticed that 2 days before his admission, he attended
the emergency department complaining of chest pain and he was told that his ECG is
normal and it was a musculoskeletal pain.

 Your Cardiology consultant noticed that he had a high troponin levels at that time
which no one checked the result and also there was T wave inversion in the ECG.
But despite that he was sent home. After discharge he had chest pain constantly
and then he came back 3 days ago and was admitted.

 Your consultant believes that his diagnosis was missed by the emergency
department as there was no follow up to the blood results.

 Assess him clinically and speak to the patient about what happened.

Dr: Hello Mr Michael ? I am Dr …. Junior doctor in the Cardiology department.

How are you doing today ? Pt: I am OK doctor.

Dr: Any chest pain ? Palpitations ? Swelling inlegs? -Pt: No

Dr: I need to examine your chest.Examiner says – chest is normal
Dr: I will check your ECG. Examiner says – ECG normal.
Dr: Mr Michael everything seems to fine now. You are recovering well.

Dr: I need to talk to you about your condition. Do you know what exactly has happened to
you?

Pt: I am told that I have a heart attack.

Dr: Yes that is right. We have treated you for that now. I understand you came to our
hospital A& E department 5 days ago. Could you please tell me why did you come to the
hospital that time and what happened in the hospital ?

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 Pt: Doctor I had pain in my chest. I came to the A&E department. They did some tests and
told me I have muscle pain and my heart is fine. I was told to go home.

Dr: Yes that is right. That is what we found out from your notes.

Dr: Mr Michael I need to tell you something that there was a mistake happened at that
time. A& E doctors did the ECG at that time which was some changes in the ECG but they
thought it was normal and they also did some blood tests which are specific for heart
attack.

They told you that you do not have any problem in the heart because the ECG they
thought was normal and also they did not check the blood result which actually showed
that you had heart problem that time. We should have kept you in the hospital and treated
you for theheartproblemthattimeitself.Iamverysorrytosaythis.Idoapologiseonbehalfofthe
hospital. This should not have happened.

Pt: But why did this mistake happen ?

Dr: Mr Michael I do not know why this mistake happened. I can only apologise to you now.
I assure that you are fine now and no serious harm has happened to you.

Pt: Who is responsible for this mistake ?

Dr : We do not know exactly who is responsible for this at this moment but we are going to look into
all this.

Pt: You people do not care for other’s life ! I would have died !

Dr: I am really sorry for what happened. I can imagine why you are feeling that way. We
do care for everyone but sometimes mistakes do happen. We do take all the measures
so that mistakes do not happen?

Pt: What will you do so that these mistakes will not happen again ?

Dr: We will investigate this matter further. We have a procedure where we report such
incidentstotheappropriateauthorities.Wehavesomethingwhatwecallas“RootCause
Analysis meeting” where we discuss such matters and take appropriate actions so that
these mistakes do not happen again. Also some actions may be taken over defaulting
persons.

We also educate staff, provide better supervision for juniors in A&E, may be a
mandatory training for staff about dealing with chest pain and may also include asking
to lab staff to call doctors if blood test results shows some serious conditions.

Pt: I would like to talk to your Consultant.

Dr: Surely you can talk to my Consultant. I will let him know about it.

Mr Michael if you like to escalate the matter further you can do it. We have a dedicated
department for this what we call as“PatientAdvisoryLiaisonService”–you can talk to
them about it.

Pt: Thank you doctor I will consider that.

Dr: I will like to reassure again that everything is fine with you now. If you need any help

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please let us know. Thank you very much.

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