Source: Health and Disability Commissioner
The importance of considering different diagnoses, and the impact that cognitive biases and a lack of critical thinking can have on diagnostic decision-making was highlighted in a decision by Health and Disability Commissioner Morag McDowell.
In her decision, Ms McDowell found Pegasus Health in breach of the Code of Health and Disability Services Consumers’ Rights (the Code), for failing to provide services with reasonable care and skill.
A woman aged in her fifties, presented to Pegasus Health with symptoms of a heart attack, and a clinical background that put her in a high-risk category for ischaemic heart disease. However, the focus throughout the five-hour period before her eventual diagnosis (of heart attack) was based on the possibility that the woman was suffering a reaction to an antibiotic.
Ms McDowell considered the woman was triaged incorrectly, and medical practitioners did not appropriately elicit her symptoms or reconsider the working diagnosis. She also concluded that conversations between nursing and medical staff were not documented, the symptoms were not documented in Pegasus Health’s electronic records, and nursing staff did not escalate care to medical practitioners.
“I am particularly concerned that the woman’s chest pain was known to the nursing staff, but apparently not to the two doctors who reviewed her. This raises questions, not just about the quality of the medical reviews, but the standard of communication between the nursing and medical staff.
“Given the whole context, a cardiac cause for the woman’s presentation should have been considered. This may have prompted further questioning of the woman, an earlier ECG, and possibly earlier diagnosis and treatment,” says Ms McDowell.
The investigation identified departures from the standard of care by multiple staff, and because of this Ms McDowell concluded that collectively these were failings for which ultimately Pegasus Health was responsible.
“Pegasus Health has a responsibility through both its staff and its processes to provide a reasonable standard of care to consumers. They should also have a system that supports good clinical decision-making, and communication and cooperation between different individual health providers. Throughout the woman’s presentation to Pegasus Health, multiple staff demonstrated a lack of effective written and verbal communication which was not supported by Pegasus Health’s expectations for staff to comply with the relevant standards and policies.
“Overall, the deficiencies that have been identified in the care provided to the woman highlights poor teamwork and a lack of critical thinking amongst multiple staff,” says Ms McDowell.
Ms McDowell recommended that Pegasus Health provide a written apology to the woman; provide evidence of all triage nursing staff attendance at the College of Emergency Nurses New Zealand (CENNZ) national triage course; use the report as a case study for training; and review and update its “Consult Documentation” policy.
She further recommended the Royal New Zealand College of Urgent Care review the use of the Australasian Triaging Scale (ATS) in urgent care clinics. ATS was developed and validated for emergency departments, not urgent care, which has a different population/case mix and different expectations of services from that population.
The full report of this case will be available on HDC’s website. Names have been removed from the report to protect privacy of the individuals involved in this case.
The Commissioner will usually name providers and public hospitals found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.
More information for the media and HDC’s naming policy can be found on our website here.
