At the Bedside

Think of malpractice prevention as part of ED patient safety. The highest-yield approach is: identify dangerous diagnoses, document your reasoning, communicate clearly, and ensure safe disposition. In adults, common litigation themes include missed MI, stroke, sepsis, ectopic pregnancy, PE, compartment syndrome, spinal cord compression, and inadequate informed refusal. In pediatrics, the big issues are missed sepsis/meningitis, child abuse, foreign body, intussusception, testicular torsion, appendicitis, missed dehydration, and failure to recognize abuse or neglect.

Practical ED steps:
  • History and exam: document onset, time course, focal symptoms, risk factors, and a targeted exam that addresses the dangerous diagnoses in play.
  • Shared decision-making / informed refusal: if a patient declines recommended care, document capacity, risks, benefits, alternatives, and return precautions.
  • Pediatrics: always consider the child’s developmental baseline, caregiver history reliability, safeguarding concerns, and whether the story fits the injury pattern.
  • If concern for abuse/neglect: prioritize safety, social work, child protection reporting, and mandatory reporting laws.
  • Discharge safety: clear instructions, follow-up plan, red-flag symptoms, and reliable supervision/access to return are critical.
  • Error prevention: use closed-loop communication, document reassessments, and avoid ambiguous “rule out” language when you have not actually excluded a dangerous diagnosis.
Disposition decision points:
  • Discharge only when the patient has a stable exam, a coherent alternative diagnosis or low-risk syndrome, reliable follow-up, and explicit return precautions.
  • Admit/observe when symptoms are unexplained, dangerous diagnoses remain plausible, or social factors make outpatient management unsafe.
  • Escalate to attending early for high-risk refusal, peds safeguarding, or any case where documentation would need to defend a high-risk decision.
A Classic Presentation
A 54-year-old man presents with chest pain and is discharged after a single negative troponin and nonspecific ECG. He returns the next day with an anterior STEMI. The case centers on a failure to recognize the need for serial testing and appropriate risk stratification, plus inadequate documentation of chest pain features and return precautions. The management lesson is to do a defensible chest pain evaluation, document your reasoning, and avoid premature closure.
Patient Presentation to Attending
How you’d present this patient on the floor
This is a 54-year-old man with hypertension and hyperlipidemia presenting with 3 hours of pressure-like chest pain. My main concern is ACS because the pain is exertional and radiates to the left arm, and that’s the diagnosis we cannot miss here. He does not have reproducible chest wall tenderness or a clearly pleuritic component, and his ECG is non-diagnostic so far, but I’m not reassured by a single negative troponin yet. Exam is otherwise stable without heart failure signs. I think he needs serial ECGs and troponins with risk stratification, and if that stays negative we can discuss observation versus discharge with very explicit return precautions.

Study Directive

  • Write a one-minute “defensible documentation” template from memory: chief complaint, dangerous diagnoses considered, key negatives, reassessment, and disposition.
  • Review 5 common ED malpractice themes and map each to the missed step: missed ACS, stroke, sepsis, ectopic, abuse.
  • Practice one informed refusal note and one pediatric discharge note with explicit return precautions.
  • Memorize when mandatory reporting is triggered in your state/hospital.
  • Read your department’s policy for high-risk refusals, pediatric transfers, and sepsis pathways.

Recent Literature