A London ambulance pulls up outside the Emergency Department at a hospital.

Clinical decision making: diagnosis of pulmonary embolism in emergency departments

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

This investigation looks at the timely recognition and treatment of suspected pulmonary embolism (PE).

A person suffering from a PE (a clot in the lung) requires urgent treatment to reduce the chance of significant harm or death.

PE can form when clots from the deep veins of the body, mostly originating in the legs, travel through the venous system and become lodged in the lungs.

The diagnostic tool most commonly used to detect PE is a computerised tomography pulmonary angiogram (CTPA). The most common treatment is giving of anticoagulants which can breakdown existing clots and prevent further clots from forming.

Any delay in recognising the symptoms of PE and treatment of the suspicion of PE increases risk that a patient may suffer harm.

Reference event

We started this investigation after analysis of evidence from another HSIB investigation: management of venous thromboembolism risk in patients following thrombolysis for an acute stroke.

At the time of investigation access to emergency departments was limited because of the COVID-19 pandemic, and the investigatory approach was therefore adapted.

Rather than examining a reference event, the investigation reviewed 14 serious incident reports obtained from hospitals across England. This review identified the terms of reference for the national investigation.

Investigation summary

The national investigation focused on emergency departments and:

  • examined clinical decision making in the diagnosis and treatment of PE and the role of expertise (significant knowledge and skill that supports effective and practical decision making) using an Applied Cognitive Task Analysis (ACTA)
  • identified factors in the wider healthcare system that support or inhibit diagnostic decision making when staff are seeing patients with non-specific symptoms and signs that may suggest PE.