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Medical error Missed MI

You are the medical FY 2 on the cardiologyward.

35yearsoldMrMichaelwasadmittedwithachestpain3daysagoandwastreated for
Acute inferior myocardial infarction.Now he is stable on medicaltherapy.

On looking at his notes, you noticed that 2 days before his admission, he attended
theemergencydepartmentcomplainingofchestpainandhewastoldthathisECG is normal
and it was a musculoskeletalpain.

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 wasadmitted.

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

Assess him clinically and speak to the patient about whathappened.

Dr: Hello MrMichael ? 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 checkyourECG. Examiner says ECGnormal.
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 ?
Pt:DoctorIhadpaininmychest.IcametotheA&Edepartment.Theydidsometestsand told me I
have muscle pain and my heart is fine. I was told to gohome.
Dr: Yes that is right. That is what we found out from your notes.
Dr:MrMichaelIneedtotellyousomethingthattherewasamistakehappenedatthattime. A& E
doctors did the ECG at that time which was some changes in the ECG but they
thoughtitwasnormalandtheyalsodidsomebloodtestswhicharespecificforheartattack.
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TheytoldyouthatyoudonothaveanyproblemintheheartbecausetheECGtheythought 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 havehappened.
Pt: But why did this mistake happen ?
Dr:MrMichaelIdonotknowwhythismistakehappened.Icanonlyapologisetoyounow. I assure
that you are fine now and no serious harm has happened toyou.
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 others life ! I would have died !
Dr: I am really sorry for what happened. I can imagine why you are feeling that way. We
docareforeveryonebutsometimesmistakesdohappen.Wedotakeallthemeasuresso that
mistakes do nothappen?
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.WehavesomethingwhatwecallasRootCause
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
departmentforthiswhatwecallasPatientAdvisoryLiaisonServiceyoucantalkto them
aboutit.
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
please let us know. Thank you very much.