Quick decisions are the most common cause of misdiagnosis, a leading United States emergency nurse practitioner (ENP) warned nurses in Melbourne last month.

Nurses were under pressure to make split second decisions which often led to quick diagnosis, Californian ENP Karen Hoyt told delegates at the 6th Australian Emergency Nurse Practitioners’ Symposium. “You land on things very quickly and most the time you’re right – but what if you’re wrong, especially with trauma? You can miss injuries with trauma.”

In St Mary’s Medical Centre in Long Beach where Professor Hoyt practices, two ENPs see 200 patients a day from 9am to 1pm. “We are always on the clock. We see 75% of all patients and discharge 50%.”

Adjunct Clinical Professor of the University of San Diego and ENP of 15 years, Professor Hoyt described seven areas of clinical errors. The most common area “premature closure” included jumping to conclusions, not looking for a second injury, making a quick diagnosis or a suspected diagnosis not confirmed by appropriate testing. Faulty assessment included over- or under-estimating a disease likelihood; and failure to consider all relevant possibilities.

Editor of the Advanced Emergency Nursing Journal, Professor Hoyt said ENPs should consider as many differential diagnoses as possible. “Ninety per cent of is in the history. Your differential diagnoses are swirling about in your head before you even walk in the room.

“The more you practice, the more you see, the more you get better but don’t hone into the diagnosis too quickly because you can be fooled. You need to think wide, big and deep in trauma.”

No practitioner was immune to missed injuries, no matter how good they were, said SA Emergency Physician Dr Andrew Wilkinson. “When you find the first injury, do not stop looking. With paediatric fractures there are often more than one.”

Dr Wilkinson’s tips included having all x-rays reviewed by a consultant radiologist; ignoring external pressures when walking into a patient cubicle; and having a systematic, methodical approach. “There might be other things in your head. You might be thinking about the 15 patients waiting or the patient you’ve just seen that isn’t sorted out yet.
“We cannot obliterate missed injuries but we can reduce the likelihood of them.”

Republished with permission from the Australian Nursing & Midwifery Journal