Pulmonary Embolism Missed in the Emergency Room — How These Malpractice Cases Get Built

A pulmonary embolism is a blood clot — usually one that formed in a deep vein of the leg or pelvis — that breaks loose, travels through the heart, and lodges in the arteries of the lungs. A large clot can stop blood from crossing the lungs almost instantly and cause sudden collapse and death. Smaller clots strain the right side of the heart and can kill more slowly over hours. What makes a missed PE so tragic, and so litigated, is the gap between how treatable it is and how lethal it becomes when it is not caught. Caught in the emergency room, the standard treatment — blood-thinning medication, and in the most severe cases clot-dissolving drugs or a catheter procedure — is highly effective. Missed, the same clot can be fatal within hours.

Pulmonary embolism is also one of the most frequently missed serious diagnoses in all of emergency medicine, because it borrows the symptoms of far more common problems — a chest cold, pneumonia, a panic attack, a pulled muscle, an asthma flare, or a heart attack. A patient who arrives short of breath or with chest pain that worsens on a deep breath can be labeled with any of those and sent home while a clot is still in the lungs. This guide walks through how a PE is supposed to be recognized in the emergency room, the patterns of failure that produce these cases, the time-stamped records that decide them, and what families should preserve when they believe a pulmonary embolism was missed.

The Pulmonary Embolism Picture in U.S. Emergency Rooms

Venous thromboembolism — the umbrella term for deep vein thrombosis and pulmonary embolism — affects hundreds of thousands of Americans every year and is a leading cause of preventable death in hospitals. In the emergency department, the challenge is not that PE is exotic but that it is buried in an enormous volume of patients who present with chest pain and shortness of breath, the overwhelming majority of whom do not have a clot.

The result is a diagnosis that is missed at first contact far more often than it should be. A 2022 systematic review of the literature by Kwok and colleagues found that roughly 27.5 percent of pulmonary embolism patients were misdiagnosed at their initial emergency-department presentation, and that the misdiagnosis rate was even higher — about 53.6 percent — among patients already admitted to the hospital. The same review identified the labels most often assigned instead of PE: respiratory infection, heart failure, and acute coronary syndrome. In other words, more than one in four patients who turn out to have a clot in the lungs walk out, or are admitted for something else, carrying a diagnosis that was wrong.

Why the Clock Matters

Pulmonary embolism is the rare emergency where the treatment is both simple and dramatically effective, which is precisely why a delay is so hard to defend. Prompt anticoagulation stops new clot from forming and lets the body break down what is already there; for a massive PE causing shock, clot-dissolving thrombolytics or a catheter-directed procedure can be lifesaving. The older, often-quoted figure that untreated PE carries a mortality on the order of 25 to 30 percent comes from historical autopsy and inpatient data and should be read with caution — but no one disputes the core point the guidelines make: PE is highly treatable when it is recognized and dangerous when it is not.

The Standard of Care: The 2019 ESC/ERS Guideline and a Structured Pathway

The reference most experts return to is the 2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism, developed by the European Society of Cardiology with the European Respiratory Society and mirrored in U.S. emergency-medicine practice and American College of Emergency Physicians clinical policy. The guideline's central instruction is that PE is diagnosed not by hunch but by a structured, stepwise pathway that keeps the clot on the table while avoiding a CT scan for every patient with chest pain:

• Step one — estimate the clinical (pretest) probability. Using a validated score such as the two-tier Wells score or the revised Geneva score, the clinician sorts the patient into PE-likely or PE-unlikely based on risk factors, heart rate, signs of a leg clot, prior VTE, recent surgery or immobilization, cancer, and whether PE is the most likely explanation.
• Step two — apply the PERC rule to the lowest-risk patients. A patient the clinician judges low-risk who satisfies all eight Pulmonary Embolism Rule-out Criteria (PERC) has a low enough probability that no further testing is needed. Any positive criterion, or a higher pretest probability, moves the patient forward.
• Step three — use D-dimer to sort who needs imaging. For PE-unlikely patients who are not PERC-negative, a D-dimer blood test is drawn. A normal result, interpreted with an age-adjusted cutoff in patients over 50, makes PE unlikely enough to safely stop. An elevated result means imaging.
• Step four — confirm with imaging. CT pulmonary angiography (CTPA) is the definitive test and the method of choice; a ventilation-perfusion (V/Q) scan is the alternative when CT is contraindicated, for example in pregnancy or contrast allergy.

The importance of this pathway is that it is objective. Each step has a documented input and a documented output, which is exactly what lets a reviewing expert — on either side — measure what the ER actually did against what the guideline told it to do.

The Diagnostic Workup That Should Happen

When a patient arrives with symptoms that could be a PE — unexplained shortness of breath, chest pain that is worse on a deep breath, a fast heart rate, coughing up blood, a swollen or painful leg, or a fainting spell — the standard emergency workflow tracks the guideline:

1. A history that asks about clot risk. Recent surgery, hospitalization, or a long flight; a leg that is swollen or tender; a personal or family history of clots; active cancer; estrogen-containing birth control or hormone therapy; pregnancy or a recent delivery. These are the details that populate the risk score.
2. Vital signs read as clues, not noise. An unexplained fast heart rate or a low oxygen level in a patient who should not have one is a red flag that belongs in the differential, not a number to be treated in isolation.
3. A structured pretest probability. The Wells or Geneva score is calculated so the next step is driven by a number rather than a gestalt impression.
4. PERC for the low-risk, D-dimer for the rest. A truly PERC-negative low-risk patient can be reassured; everyone else who is PE-unlikely gets a D-dimer, read against an age-adjusted cutoff.
5. CT pulmonary angiography for definitive diagnosis. A PE-likely patient, or any patient with an elevated D-dimer, proceeds to CTPA (or a V/Q scan when CT is not appropriate). A normal chest X-ray and a normal ECG do not rule out a pulmonary embolism.
6. Prompt treatment once suspicion is high. When PE is strongly suspected and the patient is unstable, anticoagulation should not wait for the scan; a confirmed PE is treated immediately, and a massive PE triggers consideration of thrombolysis or a catheter procedure.

Why Pulmonary Embolism Gets Missed

The central trap is anchoring. Because shortness of breath and chest pain are overwhelmingly caused by things other than a clot, a clinician who settles early on the common explanation may never calculate a risk score at all. The patient with a fast heart rate is told it is anxiety. The patient short of breath is treated for an asthma flare or a chest infection. The patient with pleuritic pain is diagnosed with a muscle strain. Each of these is far more common than PE, so the anchoring is understandable — but the standard of care exists precisely to force the question "could this be a clot?" before the more comfortable answer is accepted.

A second, dangerous pattern is the "too young and healthy to have a clot" dismissal. PE occurs in young adults, and specific risk factors — estrogen-containing contraception, pregnancy and the postpartum period, recent long travel, or a recent injury or surgery — raise the risk in exactly the patients clinicians are most tempted to reassure. A young woman on birth control who arrives short of breath is a classic missed-PE fact pattern.

The Patterns of Failure

The "it's just anxiety" or panic-attack discharge

An unexplained fast heart rate and shortness of breath are attributed to a panic attack, the patient is reassured or given an anti-anxiety medication, and no risk score, D-dimer, or imaging is documented. When the chart shows tachycardia in a patient with clot risk factors and the discharge diagnosis is anxiety, the omission stands out.

The "chest cold, pneumonia, or asthma" label

Respiratory infection and heart failure are, per the literature, among the most common labels applied instead of PE. The patient is treated for a lung infection or a COPD/asthma exacerbation and sent home while the clot remains, sometimes after a chest X-ray that looks unremarkable and is wrongly treated as reassuring.

The pretest score and PERC that were never applied

The elements needed to score the patient are sitting in the history and vitals, but no Wells or Geneva score is calculated and PERC is never checked, so a patient who would have screened as needing testing is managed on impression alone.

The elevated D-dimer that was never worked up

A D-dimer is drawn and comes back elevated, but the result is not acted on — no CT angiography is ordered, or the abnormal value is lost in a busy department and the patient is discharged. An abnormal D-dimer without follow-through is one of the hardest omissions to defend.

The falsely reassuring X-ray and ECG

A normal or near-normal chest X-ray and a non-specific ECG are treated as proof the lungs and heart are fine. Because neither test rules out a PE, stopping the workup there when suspicion remains is a recurring and preventable deviation.

The premature discharge without return precautions

The patient is sent home without imaging, without a documented risk assessment, and without clear instructions on the warning signs that should bring them back — only to return, or not return, with a larger or fatal embolism.

What the Records Show

Missed-PE cases are won and lost on a small set of time-stamped entries, most of which live in the electronic medical record:

• Time of arrival (door time) and the chief complaint and symptom description recorded at triage.
• Triage vital signs — heart rate, respiratory rate, and oxygen saturation, and whether an abnormal value was flagged or repeated.
• The documented history — recent surgery, immobilization, travel, cancer, hormone use, pregnancy, prior clots, and leg symptoms.
• Any recorded Wells, Geneva, or PERC assessment, and the differential diagnosis the physician wrote down.
• D-dimer order and result times, and whether an elevated result was acted on.
• The time definitive imaging (CT pulmonary angiography or V/Q scan) was ordered, performed, and read — often the single most important interval.
• Any treatment given or withheld, including whether anticoagulation was started when PE was suspected.
• Discharge diagnosis, instructions, and return precautions if the patient was sent home — and any return-visit, readmission, or autopsy records.

The cases get built in the gaps between these time stamps — the points where the standard pathway called for a next step the chart shows never happened.

The Medical-Legal Read

What separates a defensible bad outcome from a provable deviation is usually buried in the timing and the omissions, and reading it takes both clinical and legal training. At The Alvarez Law Firm, Herb Borroto, M.D., J.D. (Medical-Legal Expert) reviews the emergency record the way a physician reads a chart — checking whether the clot risk factors were asked about and captured, whether an unexplained fast heart rate or low oxygen level was flagged or brushed aside, whether a pretest score and PERC were applied, and whether an elevated D-dimer was ever carried forward to imaging. Alex Alvarez (Managing Partner, Board Certified Civil Trial Lawyer) then frames that record for a jury: not as hindsight, but as a series of measurable choices against a published, objective diagnostic pathway. This combination — a doctor reading the medicine and a board-certified trial lawyer proving the case — is how a missed-PE claim is tested before it is ever filed.

Proving Causation and Damages

In a missed-PE case, causation is the battleground. The defense will argue the embolism was catastrophic and unsurvivable from the outset, or that the outcome would have been the same regardless of when it was diagnosed. To answer that, an emergency-medicine or pulmonary expert reconstructs the window: what the clot burden and the patient's vital signs were at the first presentation, whether a timely CTPA would more likely than not have found a treatable clot, and how the delay changed the odds. Because PE responds so well to prompt anticoagulation, the "it would not have mattered" defense is often harder to sustain here than in other missed-diagnosis cases. The damages picture commonly includes:

• Past and future medical care, including hospitalization, long-term anticoagulation, and treatment of any lasting heart or lung injury such as chronic thromboembolic pulmonary hypertension.
• Lost wages and loss of future earning capacity when a working-age patient is left disabled.
• Pain, suffering, and loss of enjoyment of life.
• Loss of consortium for a spouse.
• Wrongful-death damages when the embolism was fatal. See our guide to medical malpractice filing deadlines for the statute-of-limitations picture.

What Families Should Preserve

When you believe a family member's pulmonary embolism was missed or delayed in the ER, the first 30 to 90 days are when the records are most accessible:

• Request the full emergency-department record under the federal HIPAA right of access — not just the summary discharge document. The triage log, nursing notes, vital-sign flowsheet, and imaging time stamps are the critical detail.
• Ask specifically for the vital-signs flowsheet (heart rate and oxygen readings), any D-dimer order and result, and any imaging orders, reports, and the images themselves with their times.
• Preserve any 911 recording and EMS run report — the paramedic narrative often contains the original symptom-onset time and the first vital signs.
• Save text messages or call logs that document when symptoms started and what was said at the visit.
• Note the name of every physician, nurse, and consultant involved.
• If the patient was transferred, request records from both facilities, and if the embolism was fatal, preserve any autopsy report — an autopsy frequently confirms the diagnosis that was missed in life.

Our guide to the medical records your lawyer needs walks through the broader request process, and our overview of the four elements of a malpractice claim explains what each case has to prove.

Frequently Asked Questions

Is a missed pulmonary embolism in the ER always malpractice?

No. A missed or delayed pulmonary embolism is malpractice only when the emergency room's care fell below the accepted standard and that failure caused harm the patient would otherwise have avoided. PE can present in vague ways and overlaps with common conditions, so the question is not simply whether it was missed, but whether a reasonable ER, faced with the same symptoms and risk factors, should have considered PE and worked through the standard pathway of pretest probability, D-dimer, and imaging.

How is pulmonary embolism supposed to be diagnosed in the emergency room?

The 2019 ESC/ERS guideline directs emergency clinicians to first estimate the clinical probability of PE using a structured score such as the Wells or revised Geneva score. Low-risk patients who meet all eight PERC criteria need no further testing. Otherwise a D-dimer blood test — interpreted with an age-adjusted cutoff for patients over 50 — decides who proceeds to imaging. CT pulmonary angiography is the definitive test that confirms or excludes the clot.

What conditions is pulmonary embolism most often mistaken for?

A systematic review found the diagnoses most commonly assigned instead of PE are respiratory infection (such as pneumonia or bronchitis), heart failure, and acute coronary syndrome. PE is also frequently dismissed as anxiety or a panic attack, a musculoskeletal chest strain, or an asthma flare — especially in younger patients who are wrongly assumed to be low-risk. Because these alternatives are far more common than PE, clinicians can anchor on them and stop the workup too early.

How long do I have to file a missed-pulmonary-embolism malpractice case?

The deadline depends on the state, and most states run a statute of limitations from when the injury was or should have been discovered, subject to an outer statute of repose. Because these clocks are short and pre-suit steps take time, families should confirm their state's deadline early rather than assume.

If You or a Family Member's Pulmonary Embolism Was Missed

Free, confidential case review. We work nationwide with families whose pulmonary-embolism care was delayed or whose PE was misdiagnosed in the ER.

• Read about ER malpractice generally: Emergency Room Errors.
• Read about missed aortic dissection (another can't-miss chest-pain emergency): Aortic Dissection Missed in the Emergency Room.
• Read about missed heart attack: Heart Attack Missed in the Emergency Room.
• Read about missed stroke: Stroke Missed in the Emergency Department.
• Read about missed sepsis: Sepsis Missed in the Hospital.

Free case review. No fees unless we recover compensation for you.

Sources

• Konstantinides SV, Meyer G, et al. — "2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism developed in collaboration with the European Respiratory Society (ERS)." European Heart Journal, 2020;41(4):543–603. academic.oup.com
• Kwok CS, et al. — "Misdiagnosis of pulmonary embolism and missed pulmonary embolism: A systematic review of the literature." Health Sciences Review, 2022. sciencedirect.com
• Stein PD, et al. (PIOPED II Investigators) — "Multidetector Computed Tomography for Acute Pulmonary Embolism." New England Journal of Medicine, 2006;354:2317–2327. nejm.org
• Freund Y, et al. (PROPER Investigators) — "Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients." JAMA, 2018;319(6):559–566. jamanetwork.com
• Righini M, et al. (ADJUST-PE Study) — "Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism." JAMA, 2014;311(11):1117–1124. jamanetwork.com
• American College of Emergency Physicians — Clinical policy on the evaluation and management of adult patients with suspected acute venous thromboembolic disease. acep.org