• diagnostic errors
• emergency department
• human error

Thirteen years ago, only a few months after completing my residency in emergency medicine, I walked into a night shift ready for anything. One of the first patients I encountered was a young man with right-sided thoracic back pain after having spent a day lifting moving boxes. Acute back pain is of course a common reason for people to visit an emergency department, and along with his age, the location and context of the pain seemed fairly typical for muscular strain. But as a junior attending I was appropriately more conservative than how I suspect I would act today. Responding to my nerves, an elicited history of cocaine use and leucocytosis, we ordered an MRI of the back to look for an epidural abscess and treated his pain.

The MRI was performed and reported as a normal study. While we assessed whether he was comfortable for discharge, I proceeded to focus my attention on other patients who required immediate stabilisation and management. Sometime later during the shift I was suddenly startled by a low-pitched thud near my desk. I looked over and saw someone in a patient gown lying on the floor. Sprinting over to that spot, I soon realised it was this young man collapsed onto the floor in cardiac arrest. During the ongoing resuscitation, the proverbial light bulb went off in my head and I sent the resident physician back to speak with the radiologist again about the MRI, focusing specifically on the aorta. By the time we confirmed a type A aortic dissection ruptured into the right hemithorax and attempted to rush the patient to the operating room, it was too late.

Despite our best efforts, he died.

Nothing in my medical training up to that point prepared me for such failure. During medical school and residency …