Would I be considered negligent if a patient has pulmonary embolism (PE) and I didn’t rule it out?

Legal Liability for Missing Pulmonary Embolism Diagnosis

Failure to properly evaluate a patient with suspected pulmonary embolism (PE) using validated clinical prediction rules and appropriate diagnostic testing could be considered negligent, especially if the patient has risk factors or clinical signs suggesting PE. 1

Standard of Care for PE Diagnosis

Clinical Evaluation

• Clinicians should use validated clinical prediction rules (such as Wells criteria or revised Geneva score) to estimate pretest probability in patients with suspected PE 1
• The absence of all three clinical features - tachypnea (>20/min), pleuritic pain, and arterial hypoxemia - can effectively exclude PE diagnosis 1
• Young women on oral contraception with isolated pleuritic chest pain are unlikely to have PE if they have no other risk factors and either are under 40 or have a respiratory rate <20/min plus normal chest radiograph 1

Diagnostic Algorithm

• For patients with low pretest probability who meet all Pulmonary Embolism Rule-Out Criteria (PERC), no further testing is needed 1
• For patients with intermediate pretest probability or low probability not meeting PERC criteria, high-sensitivity D-dimer measurement should be the initial diagnostic test 1
• Age-adjusted D-dimer thresholds (age × 10 ng/mL rather than generic 500 ng/mL) should be used in patients older than 50 years 1
• No imaging studies should be obtained if D-dimer level is below the age-adjusted cutoff 1
• For patients with high pretest probability, CT pulmonary angiography (CTPA) should be obtained without D-dimer testing 1

Legal Implications of Missing PE

Negligence Standards

• Failure to follow established diagnostic protocols for PE evaluation could constitute a breach of the standard of care 1
• Clinicians are expected to stratify patients with suspected PE based on clinical presentation and risk factors to determine appropriate diagnostic pathways 1
• The European Society of Cardiology (ESC) guidelines explicitly state that clinicians should "use validated diagnostic criteria" in suspected PE without hemodynamic instability 1

Documentation Requirements

• Clinical decision-making should be clearly documented, including assessment of pretest probability using validated tools 1
• When PE is suspected but not pursued, documentation should include clear rationale for why alternative diagnoses were considered more likely 1
• A recent survey showed that failure to comply with evidence-based diagnostic strategies when withholding anticoagulation despite clinical suspicion of PE was associated with significant increases in VTE episodes and sudden death in the 3-month follow-up period 1

Avoiding Pitfalls in PE Diagnosis

Common Errors

• Overreliance on a single symptom or sign to rule out PE (PE can present with nonspecific symptoms) 2, 3
• Failure to recognize high-risk patient groups (post-surgical, trauma, malignancy, pregnancy) 2, 4
• Not adjusting D-dimer thresholds for age in older patients 1
• Inappropriate use of imaging in low-risk patients who meet PERC criteria 1

Best Practices to Avoid Liability

• Apply structured risk assessment using validated tools (Wells score, Geneva score) 1
• Document clinical reasoning, especially when deciding not to pursue PE workup 1
• Follow guideline-recommended diagnostic pathways based on risk stratification 1
• Consider PE in patients with unexplained dyspnea, hypoxia, and normal chest radiograph 1, 4
• Recognize that PE is both overdiagnosed and underdiagnosed in clinical practice 1, 3

Special Considerations

High-Risk Scenarios

• Patients with shock or hypotension require immediate evaluation with bedside echocardiography or emergency CTPA 1
• Patients with high clinical probability should receive immediate anticoagulation while diagnostic workup is in progress 1
• Post-surgical patients, especially after abdominal surgery, present diagnostic challenges and PE may be confused with segmental/lobar collapse or infection 1

Balancing Risks

• While missing PE can be fatal, overdiagnosis leads to unnecessary anticoagulation with its own risks 1, 2
• Evidence suggests that untreated patients with smaller emboli have a lower recurrence rate than previously thought, but this does not justify omitting proper diagnostic evaluation 1, 4