KUALA LUMPUR, July 2 — Health Minister Dzulkefly Ahmad has acknowledged the possibility of a misdiagnosis in the case of a Sabahan teen who died from dengue fever after visiting Tuaran Hospital.
Dzulkefly told the Dewan Rakyat special chambers last June 26 that it was “a bit of a mistake” for the government hospital to not admit the 18-year-old patient despite symptoms like repeated vomiting.
“I observed that there was a possibility of misdiagnosis due to confusion in handling the signs and symptoms within the differential diagnosis. Overlooking that the patient had vomited five times was already a warning sign that should not have been taken lightly, and to discharge a patient like that could be considered a misdiagnosis,” Dzulkefly stated.
“Initially and repeatedly, they came after taking PCM or paracetamol, Panadol, so the fever was not apparent. Because of that, the signs and symptoms were perhaps masked due to the medication they had taken, like PCM and others. This often results in patients, or clinicians, especially the younger ones, MOs (medical officers), misdiagnosing.”
The health minister was speaking in the Dewan Rakyat special chambers on a matter called by Tuaran MP Wilfred Madius Tangau about misdiagnosis in hospitals’ emergency departments.
Dengue fever symptoms can resemble those of other common illnesses, such as fever, headache, nausea, vomiting, rash, or joint pain, particularly in the early stages, Dzulkefly added. This similarity with other diseases often leads to inaccurate diagnoses.
“Each attending physician employs what is known as a differential diagnosis, where they make an initial diagnosis and develop an approach to ultimately determine the final, accurate diagnosis.
“However, what we are most concerned about is misdiagnosis during the initial triaging process. When a patient comes to the emergency department (ED), they are categorised into green, yellow, or red zones.
“This triage determines the fate of a patient — whether they will receive immediate treatment or, as in this case, be discharged or not admitted and instead given medications such as Axolon, antiemetics for nausea, and Ranitidine for dyspepsia or heartburn,” Dzulkefly said.
Aidil @ Erjuand Christian, an 18-year-old from Kampung Bulieng, Tuaran, in Sabah, died from hemorrhagic dengue fever, after he was allegedly diagnosed by Tuaran Hospital with a simple fever last December 25 and sent home with medication. His parents claim that their son was not tested for the virus during that first visit.
Three days later, Aidil’s condition worsened, and a blood test confirmed dengue fever. Aidil was transferred to Queen Elizabeth I Hospital in the Sabah state capital of Kota Kinabalu, but succumbed to his illness on December 29.
Madius, who highlighted the tragedy, said the outcome might have been different “if the disease had been diagnosed more accurately during the initial visit.”
More than 138 million patients worldwide are affected each year due to medical negligence. According to the World Health Organization (WHO), 2.6 million patients die annually as a result of such negligence.
The three main causes identified are medical errors in diagnosing diseases, errors in prescribing and administering treatment, and giving incorrect medication to patients.
Minister Concerned About Deploying MOs Who Lost Clinical Skills To ED
Dzulkefly highlighted the critical need for continuous training, especially among junior doctors, to manage medical cases effectively.
“Training in the management and treatment of dengue cases will continue to be strengthened among health care personnel, especially early MOs.
“Two, three years is still, you know, they still require extensive training and exposure, especially in handling dengue patients. This is essential to uphold service quality and ensure patient safety,” Dzulkefly said.
He highlighted the importance of ongoing mentoring and coaching for all health care personnel, including junior MOs, provided by seniors across various medical specialties.
Dzulkefly said he was concerned over previous efforts to bolster MO numbers in the ED to cope with shortages. “Calling upon any MOs can lead to a loss of clinical skills, as medicine revolves around these skills and making informed judgements. MOs who have lost clinical skills may end up in specialties like psychiatry.”
He added, “No disrespect to psychiatry, but clinical skills for ED triage differ and were once universally acquired but may now be diminished. Therefore, the deployment of any MOs in EDs must ensure thorough training and ongoing skill development.”
Last January, the Ministry of Health (MOH) instructed the rotation of MOs, particularly those from non-clinical backgrounds, to the Green Zone (non-critical cases) of emergency departments in government hospitals nationwide to improve patient waiting times to two hours. Some dissenting medical officers at Queen Elizabeth Hospital cited potential patient harm from this directive.
Up To 80 Per Cent Of Emergency Cases Are Common Cold, Cough, URTI Cases
Dzulkefly pointed to several issues in emergency health care, highlighting that up to 80 per cent of cases are mild, such as common colds and upper respiratory tract infections (URTI).
This influx of non-critical cases can overwhelm EDs, diverting attention from urgent medical emergencies. To mitigate this, programmes have been introduced to extend clinic hours, easing congestion in EDs, and ensuring that critical cases receive prompt attention.
Central to the ministry’s concerns is the triaging system’s effectiveness in prioritising patient care upon arrival at emergency departments. Dzulkefly said it is crucial to avoid under-triaging, as it can lead to inadequate care for genuine emergencies.
Monitoring through hospital performance indicators shows progress, with under-triaging rates decreasing significantly from 0.14 per cent in 2014 to 0.03 per cent in 2023, though continuous improvement remains a priority.
“This is very important, and the issue is that the ED staff are frontliners. They are the ones who determine how a patient will be − after triaging, they will be placed on their treatment plan. So if they miss that − usually ED does not miss,” Dzulkefly said.
Teach Patients And Caregivers About Symptoms Upon Discharge
Effective communication between patients, caregivers, and health care providers is crucial, especially at the time of patient discharge.
Dzulkefly emphasised the importance of doctors clearly explaining the diagnosis, treatment plans, and warning signs to patients and their families.
This ensures that if symptoms like vomiting or fever develop, patients can promptly return to the hospital or utilise digital teleconsultation services to update their doctors.
“These steps are absolutely crucial, particularly when patients are discharged. If symptoms such as vomiting or recurring fever arise, they should immediately return to the hospital or use digital teleconsultation to inform and update the doctors. It’s essential so that warning signs, red flags, are promptly addressed by the hospital and doctors.
“In the later phase, it’s important to understand that dengue has two stages. When it progresses to the second stage, typically three days later, the patient may experience dengue shock syndrome, which involves symptoms like gum bleeding and others.
“So, even before reaching that stage, there should be follow-up after discharge. However, it was a mistake not to admit the patient earlier due to frequent vomiting and other symptoms. Therefore, effective communication between the patient, hospital, and attending doctors is crucial, whether in a clinic setting or elsewhere,” Dzulkefly said.
“Every life is precious, and on behalf of all members of the MOH, I first want to express my condolences to the families of those who have passed away. Every death is indeed a tragedy.”
Dzulkefly underscored the MOH’s serious commitment to addressing this issue and improving management to prevent such tragedies in the future.
