Is it considered malpractice if a doctor doesn't rule out Pulmonary Embolism (PE)?

Failure to Rule Out Pulmonary Embolism: Medical-Legal Considerations

Not ruling out pulmonary embolism (PE) when clinically indicated can constitute malpractice, especially when validated clinical prediction rules and diagnostic algorithms are not followed appropriately. 1

Standard of Care for PE Evaluation

The standard of care for evaluating suspected PE involves a structured approach:

1. Clinical Probability Assessment

   • Clinicians must use validated clinical prediction rules (Wells score or revised Geneva score) to estimate pretest probability 2, 1
   • This assessment is considered best practice by the American College of Physicians 2

2. Appropriate Testing Based on Risk Stratification

   • Low probability patients meeting PERC criteria: No further testing needed 2, 1
   • Low probability not meeting PERC or intermediate probability: D-dimer testing required 2
   • High probability patients: Direct imaging with CT pulmonary angiography without D-dimer testing 2, 1

3. Age-Adjusted D-dimer Thresholds

   • For patients over 50 years: Age × 10 ng/mL rather than generic 500 ng/mL cutoff 2, 1
   • No imaging studies should be obtained if D-dimer is below age-adjusted cutoff 2

When Failure to Rule Out PE May Constitute Malpractice

Malpractice considerations arise when:

• Failure to Follow Established Guidelines: Not adhering to published diagnostic algorithms from major medical societies 2, 1
• Ignoring Clinical Probability: Disregarding clinical prediction rules when evaluating patients with symptoms suggestive of PE 2
• Misinterpreting Test Results: Particularly misinterpreting non-diagnostic lung scans as confirmation of PE absence 3
• Inadequate Testing: Not ordering appropriate tests based on pretest probability 2
• Overlooking High-Risk Presentations: Failing to recognize and appropriately manage patients with high-risk PE presentations 2

Common Pitfalls Leading to Potential Malpractice

1. Overreliance on Clinical Judgment Alone

   • The British Thoracic Society notes that PE is both underdiagnosed and overdiagnosed in clinical practice 2
   • Clinicians historically have poor ability to assign clinical probability without using structured tools 2

2. Misinterpretation of Diagnostic Tests

   • Over-reliance on ventilation/perfusion scanning without understanding its limitations 2, 3
   • Failure to recognize that a non-diagnostic scan does not exclude PE 3

3. Inadequate Follow-up

   • Not ensuring appropriate follow-up for patients with suspected PE 2
   • Failing to reassess patients with persistent or worsening symptoms 1

4. Ignoring Risk Factors and Clinical Presentation

   • Not considering predisposing factors for thromboembolism 2
   • Dismissing symptoms like dyspnea, tachypnea, pleuritic chest pain, or tachycardia without appropriate evaluation 1

Avoiding Malpractice in PE Evaluation

To avoid potential malpractice claims:

• Follow Established Guidelines: Adhere to diagnostic algorithms from major medical societies 2, 1
• Document Clinical Decision-Making: Clearly document risk assessment, test selection rationale, and interpretation 2
• Use Appropriate Testing Sequence: Follow the recommended testing cascade based on pretest probability 2, 1
• Consider Consultation: Involve specialists or multidisciplinary PE response teams for complex cases 1
• Ensure Adequate Follow-up: Arrange appropriate follow-up for patients with suspected PE, even if initial testing is negative 2

Special Considerations

• Pregnancy: Special diagnostic pathways including CTPA or V/Q lung scan should be considered for pregnant patients 2
• Cancer Patients: Require specific consideration in diagnostic and treatment approaches 2
• Post-Surgical Patients: PE is often confused with other conditions in post-surgical settings, requiring heightened vigilance 2

The evidence clearly shows that following established diagnostic algorithms significantly reduces both the underdiagnosis and overdiagnosis of PE, which is essential for avoiding potential malpractice claims.