Top 5 Reasons for Liability in the Emergency Department

The emergency department (ED) is one of the most high-pressure environments in health care. I was well aware of these risks of liability in the emergency department a week ago when I brought my husband to the local ED.

Physicians and staff are required to make rapid decisions, often with limited information, while managing multiple critically ill patients at once.

While this fast-paced setting is essential for saving lives, it also creates significant risk for medical errors and, ultimately, liability in the emergency department. Understanding the most common sources of liability can help healthcare providers reduce risk and improve patient outcomes.

The fall

About 7 PM, my husband lost his balance while rushing to get home before the rain started. Our friends heard him fall in front of their house, helped him to his feet, and called me.

When I reached him, he had a laceration over his eyebrow, which had bled profusely; his face, forearms, and pant knees were saturated with blood. The white baseball cap was splattered with blood; it was a goner. We applied pressure and ice to his head. His helpful Apple watch detected a fall and was ready to call 911 for him.  I did not see any reason why he needed EMS. He could walk. Nothing looked broken.

Our friend drove him to our house, where I helped him change clothes and eat dinner before we left for the ED. (I knew we would not get food at the hospital.)

We got there about 9 PM and got sent to the treatment area about 9:30 PM. As the triage nurse took us back to the treatment area, I was amazed at the size of the unit. She told me they had the capacity to treat 200 patients. “Two hundred patients! You must have very good processes in place to keep all of that straight.” She gave me a slight eye roll and admitted that it worked – most of the time. I decided that was not the time to tell her I am a legal nurse consultant.

From that point on, we were moved through the system, one slow step at a time, to get a tetanus booster, a dose of Tylenol, CTs of the face, head, and neck, and hand x-rays. (My husband had bruises on his hands from the fall.) All testing was negative. The last step, which occurred about 1:30 AM, involved suturing.

The ED doctor asked the ED nurse to put lidocaine ointment on a dressing and wrap it around his head so that the area would be numb. Although she did that, the step she omitted was she did not put a telfa dressing over the laceration. Instead, the gauze soaked up the lidocaine, resulting in his need to get lidocaine injections before suturing.

I overheard the ED doctor’s quiet instruction to the ED nurse about what she did wrong, and the nurse’s apology, right before the doctor arrived at my husband’s side with a handful of saline syringes to irrigate the wound and lidocaine syringes.

Just after she injected 5 spots in my husband’s forehead, I heard, “Cardiac arrest, Seventh Floor.” Apparently, the ED doctors are expected to go to codes. She said, as she got ready to leave, “I promise I won’t forget about you.”

It is impossible to argue that suturing a head wound is more important than attending a code. I mentally added another hour to our stay. However, the doctor was back in 20 minutes, explaining that the patient needed to be intubated and had not really coded.

After suturing, discharge instructions, and a wheelchair to get to the door, we left at 2:30 AM.

Some observations from the nurse/family perspective

1. I thought ahead to what I expected would be a long time in the ED and packed a bag with a book, a Kindle, 2 bottles of water, and 2 protein bars. My husband sipped at the water, grateful to have something. And I read when everything was quiet.
2. I was glad I was with my husband and able to accompany him to the bathroom door. The nurse did not offer him this assistance, correctly assuming I would help him. She was often out of sight and there was no way to ask for help.
3. My husband’s stretcher was in the hall. The patient next to us was waiting transport for an involuntary psychiatric admission because she was a danger to herself or others. She had an attendant with her who was constantly there. (I was not sure if she was suicidal or homicidal and I did not want to find out why she was being admitted.) The patient stared at us the entire time she was there. I avoided eye contact with her.
4. The woman across the hall was waiting for a bed upstairs. She had abnormal troponins and potassium level. When she got annoyed by the long wait, she kicked off her sneakers, which went out into the traffic area of the hall. Instinctively and to protect my husband from a fall, I quietly put them under her stretcher.
5. I was happy to see that the transport team checked my husband’s ID band to verify his identity before moving him for testing.
6. While we were waiting in the hall for x-ray, a man arrived by ambulance and was being worked up for a stroke. It was his fourth. There was a physician “examining” him on a computer monitor, that was set up in the hall outside the CT scanner. I was fascinated by this virtual assessment.
7. I’ve seen lidocaine injected multiple times for suturing and certainly have read thousands of charts that refer to suturing. When you are wide awake, not under anesthesia, and have no prior experience with suturing, it is scary. My husband’s blood pressure went up to 221/92 because of his fear of suturing. For him, it was the most frightening aspect of his care.

Of course, I was hypervigilant, acting as my husband’s advocate, watching everything that occurred, and speaking on his behalf when needed. We successfully avoided several areas of common liability in the emergency department:

1. Misdiagnosis or Delayed Diagnosis

One of the leading causes of liability in the emergency department is misdiagnosis or delayed diagnosis. Failing to correctly diagnose serious conditions like myocardial infarction, stroke, or sepsis can result in severe patient harm or death. In many cases, liability arises not because the physician lacked knowledge, but because of cognitive biases, time constraints, or failure to order appropriate tests.

My husband’s condition did not warrant ordering any diagnostic tests other than the ones he got.

2. Failure to Order Appropriate Tests or Imaging

Closely related to diagnostic errors is the failure to order necessary tests or imaging studies. Emergency providers must balance the need for thorough evaluation with concerns about cost, radiation exposure, and overcrowding. However, failing to order a CT scan, lab test, or other diagnostic tool when indicated can lead to missed or delayed diagnoses.

For example, not ordering imaging for a patient with head trauma can result in serious consequences.

The CTs scans that were done were the right ones (and completed in an amazingly short period.) It took longer to do three views of his hands.

3. Inadequate Documentation

Documentation plays a crucial role in both patient care and legal protection. In the emergency department, where providers often see dozens of patients per shift, documentation can sometimes be incomplete or rushed. However, poor documentation is a major contributor to liability.

Medical records should clearly reflect the patient’s history, physical exam findings, clinical decision-making process, and discharge instructions.

We got a copy of his medical records that included everything except for the physician’s note.

4. Failure to Communicate Effectively

Communication breakdowns are another significant source of liability in the emergency department. This includes communication between healthcare providers, as well as between providers and patients.

Poor handoffs during shift changes can result in missed information, leading to errors in care. Similarly, failing to clearly communicate test results, treatment plans, or follow-up instructions to patients can have serious consequences. Patients who do not understand their diagnosis or discharge instructions may fail to seek appropriate follow-up care, worsening their condition.

We got clear discharge instructions.

5. Improper Discharge or Failure to Admit

Deciding whether to admit or discharge a patient is one of the most critical decisions in emergency medicine. Discharging a patient too early—or without appropriate instructions—can lead to deterioration and potential legal action.

My husband’s injury did not warrant admission – fortunately. There’d be even more to worry about if he had to be an inpatient.

Conclusion

The emergency department is inherently complex and unpredictable, making it a high-risk environment for medical liability. However, many of the most common causes of liability—misdiagnosis, inadequate testing, poor documentation, communication failures, and improper discharge—are preventable with careful attention and systematic practices.

By improving diagnostic accuracy, maintaining thorough documentation, enhancing communication, and making thoughtful disposition decisions, emergency providers can not only reduce their legal risk but also deliver safer, higher-quality care. Ultimately, a proactive approach to risk management benefits both patients and healthcare professionals, fostering trust and better outcomes in one of medicine’s most challenging settings.

Hear from an emergency department physician and patient safety expert, Dr. Kayur Patel, at our 13^th LNC Success Online Conference taking place April 23, 24 and 25. His presentation is called Critical Moments, Critical Mistakes: Understanding Emergency Department Liability. Register or order the recordings here: https://legalnursebusiness.com/legal-nurse-consulting-virtual-conference-13/

Pat Iyer MSN RN LNCC is president of The Pat Iyer Group. She develops resources to assist LNCs in obtaining more clients, making more money, and achieving their business goals and dreams.

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