Risk Management Pitfalls

1. “The patient denied taking any acetaminophen.” Patients, especially suicidal ones, may not be truthful about the amount of acetaminophen they ingested. Additionally, patients who have been treating chronic pain with acetaminophen around the clock may have chronic toxicity. Because acetaminophen-induced liver toxicity is one of the few treatable forms, an acetaminophen level should be checked for any undifferentiated cause of hepatocellular injury. 

2. “The kid didn’t appear that jaundiced, so I just told his mom to have him seen by his pediatrician.” The physical examination alone is a poor predictor of serum bilirubin levels, especially in the low light of an emergency department. Even well appearing neonates should have a total and direct serum bilirubin checked. 

3. “She appeared so comfortable; I wouldn’t have thought she had a pancreatic head mass.” Painless jaundice can often indicate biliary obstruction. The chemistry panel can also help narrow the differential and determine which patients should be imaged in the ED. 

4. “The patient wasn’t encephalopathic the other day when I saw her; now she is back and obtunded.” The initial stages of hepatic encephalopathy can be subtle starting with agitation and poor memory. Patients may also be good at hiding their difficulties in public. Questioning the family about a patient’s behavior might help to detect signs of early hepatic encephalopathy. A mini mental status examination may aid in documenting a patient’s cognitive impairment. All patients with jaundice and hepatic encephalopathy should be admitted. 

5. “The patient had no abdominal tenderness, so I didn’t consider cholangitis as a possibility.” Only 50-75% of patients with acute cholangitis manifest Charcot’s triad (fever, jaundice, and right upper quandrant tenderness). These signs can be absent, especially in the elderly and immunocompromised. A high index of suspicion should be maintained in patients with fever and jaundice, especially if they have a history of gallstones or prior biliary instrumentation

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