Background

1. Case: Morning Trouble (adapted from CRICO/Risk Management Foundation, 2005) A 42-year-old uninsured woman, who had not seen a doctor in 20 years, presented to the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language. The husband reported that his wife had been experiencing chest pain since 11:00 the prior evening, which she treated with aspirin. In the morning, she had sudden onset of severe chest pain and fainted on her bed. The patient was first seen by the ED attending and then by a resident. Her initial vital signs were: HR: 107, BP: 146/99, RR:29. Her chest pain was documented as “sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation.” The patient’s medical history was documented by the resident as: “fainting spells, no family history of coronary artery disease or clots, father suffered a stroke.” Toolbox Background H&P Test Consult Notebook Incurred cost: $0.00 Select a tool from the Toolbox Time: 00:00:17

2. English as a second language Click on a keyword for more information: Is there someone with a medical background who can reliably interpret for the patient? Is English the son’s/husband’s first language? Was the history documented with the presence of an interpreter other than family members? Was there any ambiguity in taking the patient’s history? A 42-year-olduninsured woman, who had not seen a doctor in 20 years, presented to the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language. The husband reported that his wife had been experiencing chest pain since 11:00 the prior evening, which she treated with aspirin. In the morning, she had sudden onset of severe chest pain and fainted on her bed. The patient was first seen by the ED attending and then by a resident. Her initial vital signs were: HR: 107, BP: 146/99, RR:29. Her chest pain was documented as “sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation.” The patient’s medical history was documented by the resident as: “fainting spells, no family history of coronary artery disease or clots, father suffered a stroke.” Toolbox Background H&P Test Consult Notebook Incurred cost: $0.00 Time: 00:01:35

3. English as a second language Click on a question for more information A reliable interpreter with a medical background is not available. Is there someone with a medical background who can reliably interpret for the patient? Is English the son’s/husband’s first language? Was the history documented with the presence of an interpreter other than family members? Was there any ambiguity in taking the patient’s history? Save in Notebook A 42-year-olduninsured woman, who had not seen a doctor in 20 years, presented to the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language. The husband reported that his wife had been experiencing chest pain since 11:00 the prior evening, which she treated with aspirin. In the morning, she had sudden onset of severe chest pain and fainted on her bed. The patient was first seen by the ED attending and then by a resident. Her initial vital signs were: HR: 107, BP: 146/99, RR:29. Her chest pain was documented as “sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation.” The patient’s medical history was documented by the resident as: “fainting spells, no family history of coronary artery disease or clots, father suffered a stroke.” Toolbox Background H&P Test Consult Notebook Incurred cost: $0.00 Time: 00:02:09

4. Test Blood gases Chest X-Ray Blood gases $110 Lab Tests Blood cultures/ASTBlood gases AcetoneArteritis (ANA)CBC CO2 CSFGlucosePotassiumSodiumLiver (SGOT)Liver (SGPT)StoolThyroid Urinalysis Studies/Tests Angiogram Audiometry Biopsy Bone Scan Cardiac Eval Cisternogram CT EEG ECG EMG/NCS ENG Evoked Potentials Genetic Tests Ischemic Exercise Test MRA MRI Muscle Biochem Myelogram Neuropsych Testing Pap Smear Pulmonary Function Schilling Test SPECT Scan Tensilon Test Visual Fields X-rays HCO3 26 mEq/L pH 7.41 pCO2 45mmHg pO2 80 mmHg Save in Notebook Toolbox Background H&P Test Consult Notebook Incurred cost: $110.00 Time: 00:07:42

5. Test ECG Chest X-Ray ECG $1,000 Lab Tests Blood cultures/ASTBlood gases AcetoneArteritis (ANA)CBC CO2 CSFGlucosePotassiumSodiumLiver (SGOT)Liver (SGPT)StoolThyroid Urinalysis Studies/Tests Angiogram Audiometry Biopsy Bone Scan Cardiac Eval Cisternogram CT EEG ECG EMG/NCS ENG Evoked Potentials Genetic Tests Ischemic Exercise Test MRA MRI Muscle Biochem Myelogram Neuropsych Testing Pap Smear Pulmonary Function Schilling Test SPECT Scan Tensilon Test Visual Fields X-rays Click to enlarge Save in Notebook Toolbox Background H&P Test Consult Notebook Incurred cost: $1,110.00 Time: 00:08:54

6. Notebook Chest pain Shortness of breath Stroke in family history Absence of trained interpreter Age Aspirin Gender Background Final vital signs Initial vital signs H&P ECG No cardiac enzymes results Elevated glucose X-Rays Blood gases Test Absence of cardiology consult Consult

7. Notebook Key Student Chest pain Shortness of breath Stroke in family history Absence of trained interpreter Age Aspirin Gender Background Why does the student not consider these high risk? Final vital signs Initial vital signs H&P ECG No cardiac enzymes results Elevated glucose X-Rays Blood gases Test Absence of cardiology consult Consult

8. User Rating Profile in Case Progression Profile of Student’s Rating during Case Progression Cumulative mean rating of risk value accessed (Scale 1-5) (High) 5 4 Student 6529 (Moderate) 3 2 What causes the profile to shift? Baseline (Low) 1 0 (Start) Time (seconds) (End)