Is it considered malpractice if a doctor fails to rule out pulmonary embolism (PE) in a patient presenting with symptoms suggestive of PE?

Failure to Rule Out Pulmonary Embolism Can Constitute Medical Malpractice

Failure to follow established diagnostic protocols for pulmonary embolism when a patient presents with suggestive symptoms can constitute medical malpractice, as it deviates from the standard of care and puts patients at significant risk of mortality. 1, 2

Standard of Care for PE Diagnosis

The American College of Physicians and other professional societies have established clear diagnostic pathways that represent the standard of care for evaluating suspected PE:

1. Clinical Probability Assessment: Clinicians must use validated clinical prediction rules (Wells score, revised Geneva score) to estimate pretest probability in all patients with suspected PE 1, 2

2. Structured Diagnostic Algorithm:

   • Low pretest probability: Apply PERC (Pulmonary Embolism Rule-Out Criteria) - if all criteria met, no further testing needed 1
   • Low probability not meeting PERC or intermediate probability: High-sensitivity D-dimer testing required 1
   • High pretest probability: Direct imaging with CT pulmonary angiography (CTPA) without D-dimer testing 1

3. Age-adjusted D-dimer thresholds: For patients >50 years, use age × 10 ng/mL rather than generic 500 ng/mL cutoff 1

Why Missing PE Diagnosis Can Be Malpractice

1. High mortality risk: PE can lead to significant morbidity and mortality if untreated 1, 2

2. Clear diagnostic pathways exist: Well-established, evidence-based protocols are available and represent the standard of care 1

3. Common presentation: PE should be considered in any patient presenting with suggestive symptoms (dyspnea, tachypnea, pleuritic chest pain, tachycardia, anxiety) 2

4. Prevalence of symptoms: The absence of dyspnea plus tachypnea occurs in only 10% of PE cases, and only 3% of patients have neither these symptoms nor pleuritic pain 2

Pitfalls in PE Diagnosis That May Constitute Malpractice

1. Failure to consider PE: Not including PE in differential diagnosis when symptoms are suggestive 2

2. Inappropriate testing sequence: Ordering imaging studies before D-dimer in low/intermediate risk patients 1

3. Ignoring clinical prediction rules: Not using validated tools like Wells or Geneva scores 1, 2

4. Misinterpreting D-dimer results: Not using age-adjusted thresholds in patients >50 years 1

5. Dismissing symptoms: Particularly dangerous as autopsy studies show many fatal PEs were unrecognized and undiagnosed 3

Key Considerations for Clinicians

• PE symptoms can be nonspecific, requiring high clinical vigilance 4

• The standard of care requires following a structured approach to diagnosis 1, 2

• Failure to follow established diagnostic pathways when PE is reasonably suspected represents a deviation from standard of care 1, 2

• Increasing incidence of PE worldwide makes adherence to diagnostic protocols even more critical 5, 6

• The PERC criteria should only be applied to patients with low pretest probability; inappropriate application to intermediate or high-risk patients would be a deviation from standard care 1, 7

By following established diagnostic protocols, clinicians can significantly reduce the risk of missing this potentially fatal condition while also avoiding unnecessary testing in truly low-risk patients.