Pulmonary Embolism #1: Diagnostic Error and Risk Reduction

Course overview

Pulmonary embolism (PE) is the most serious complication of venous thrombosis and is the third most common cause of death in the United States, with at least 780,000 clinically apparent cases occurring annually. The overwhelming majority of deaths from PE are not the result of therapeutic failure; most are the result of prophylactic oversight or diagnostic error. Many instances of venous thromboembolism and PE are preventable, and for this reason are important causes of adverse outcomes and medical malpractice litigation. Nurses must be extremely familiar with this entity in order to improve patient safety and avoid medical errors and adverse outcomes. The delay or failure to diagnose PE is presented in two separate activities. In this activity, Pulmonary Embolism Part 1, we focus on risk factors and vital sign abnormalities. We present and discuss a number of cases and highlight the role of risk factors and vital sign abnormalities in the failure to diagnose PE. After completing this activity, nurses should be able to: integrate awareness of the reasons for the failure to diagnose PE into clinical practice in order to improve patient safety, improve documentation and decrease the risk of exposure to medical malpractice; employ risk factor analysis for PE in nursing assessments for patients who present with associated signs or symptoms; and recognize the presence of pulse-temperature disparity in patients with tachycardia in order to improve timely diagnosis and management of PE.