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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.
© Scoop Media
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