RED FLAGS

SUMMARY: Safety has greater priority than accuracy in the process of diagnosis. In addition to in the diagnosis of atypical illness, clinicians are intrinsically error-prone unless they proactively adopt protective strategies. Red Flags have been developed for abdominal pain, both in children and in suspected Irritable Bowel Syndrome, headache, back pain, eye pain and rashes.

If adverse outcomes of diagnostic errors are to be reduced, clinicians need to give safe diagnosis greater priority than accurate diagnosis.

Such "diagnosis by pay-off" ¹ may be inimical to some purist medical teachers. Nevertheless, the "accurate diagnosis" approach results in Necessary Fallibility.  The problem is that "textbook cases" of illness are the exception rather than the rule, there are usually atypical features, and some clinical presentations are so extremely unusual as to be diagnostically misleading - this animal looks more like a cat but it is actually a dog. 

Particularly in medical emergency situations, it is at least as important to know what the diagnosis is not as what it is.  Such Diagnosis by Exclusion may be intellectually unsatisfying and leave both patient and physician feeling insecure, but "chest pain Not Yet Diagnosed, but unstable angina and coronary thrombosis excluded" is much safer than "probably muscular".  Indeed, the unsatisfying and insecure nature of the uncertain diagnosis leaves patient and future caregivers appropriately open to refining the diagnosis in light of subsequent developments.  Conversely, allocating to an illness a working diagnosis or label for which there is only symptomatic treatment discourages the patient from seeking further help when symptoms change or worsen. 

In addition to Necessary Fallibility in the diagnosis of atypical illness, clinicians are intrinsically error-prone unless they proactively adopt protective strategies.

Not only are clinicians prone to premature closure in the diagnostic process, but subsequent caregivers are liable to adopt uncritically a previous diagnosis that a patient reports to them.  It is essential for patient safety that physicians attempt actively to disprove the diagnoses they make intuitively, particular in the Emergency Department ².^[]

"Red Flags" are a useful aide-memoire for a limited variety of common conditions.  These are exclusionary criteria that alert clinicians to emergency, life-threatening or serious diagnoses for which there is potential for cure or amelioration, usually within a limited window of opportunity. 

Medicolegal Implications

Red Flags have been developed for abdominal pain, both in children and in suspected Irritable Bowel Syndrome headache, back pain, eye pain and rashes.

In the event of adverse outcome of diagnostic error, medical malpractice Plaintiff counsel should look for documentary evidence that "red flags" were considered. 

Abdominal Pain

Headache

Back Pain

Eye Pain

Rash

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