A pulmonary embolism (PE) is a blood clot that has traveled to the lungs, and it is one of the most frequently missed life-threatening diagnoses in emergency medicine. The symptoms — shortness of breath, chest pain, a racing heart, lightheadedness — overlap with some of the most common and least dangerous reasons people visit an emergency room or urgent care. That overlap is exactly what makes the condition so dangerous. A patient who is told they are having a panic attack, a flare of asthma, a touch of pneumonia, or a pulled chest muscle may be sent home with an inhaler, an antibiotic, or a prescription for anxiety medication while a clot continues to grow in their lungs.

When a pulmonary embolism is recognized and treated promptly, most patients survive and many recover fully. When it is missed, the clot can enlarge, additional clots can follow, and the strain on the heart can lead to collapse and sudden death — sometimes within hours or days of the visit where the diagnosis was dismissed. For families, learning that a loved one died of a blood clot shortly after being reassured by a medical professional is devastating, and it raises a difficult question: should the clot have been found?

This article explains what a pulmonary embolism is, why it is so often mistaken for something benign, what a standard emergency workup generally looks like, and how Indiana law treats a claim for medical malpractice when a missed blood clot causes serious injury or death.

What a Pulmonary Embolism Is

A PE almost never starts in the lungs. In most cases, the clot forms first in a deep vein of the leg or pelvis — a condition called deep vein thrombosis, or DVT. If a piece of that clot breaks loose, it travels with the returning blood through the heart and lodges in the arteries of the lungs. Doctors group DVT and PE together under the term venous thromboembolism (VTE), because they are two stages of the same disease.

Once a clot blocks a pulmonary artery, blood can no longer pick up oxygen in that part of the lung, and the right side of the heart has to pump against the obstruction. A small clot may cause only mild shortness of breath or sharp pain when breathing in. A large clot, or several clots together, can drop blood pressure, starve the body of oxygen, and cause the right side of the heart to fail. According to the Centers for Disease Control and Prevention, sudden death is the first symptom in roughly a quarter of people who have a PE, and an estimated 60,000 to 100,000 Americans die of VTE each year.

Two features of this disease make it especially unforgiving when it is missed. First, clots are rarely a one-time event: the same DVT that sent one piece to the lungs can keep sending more. Second, the treatment — blood-thinning medication (anticoagulation), and in severe cases clot-dissolving drugs or catheter procedures — is widely available and generally effective when started early. A patient who is correctly diagnosed is usually started on an anticoagulant within hours. A patient who is sent home with the wrong diagnosis receives none of that protection.

Why a PE Gets Mistaken for Something Else

No single symptom announces a pulmonary embolism. The most common complaints — shortness of breath, chest pain that worsens with a deep breath, a cough, a fast heartbeat, lightheadedness, or fainting — are the same complaints that bring thousands of people to emergency rooms every day for reasons that are not life-threatening. Medical references list a long differential diagnosis for these symptoms, with pneumonia, heart conditions, anxiety, and musculoskeletal pain sitting on it alongside PE, and diagnostic-error research has repeatedly identified PE as one of the most commonly missed or delayed diagnoses in medicine.

Families who have lived through a missed PE often describe a version of the same story. Their loved one went to an emergency room or urgent care with chest tightness and trouble breathing. A chest X-ray looked normal or showed a small, vague abnormality. An EKG did not show a heart attack. The patient was then given one of a handful of reassuring explanations:

• Anxiety or a panic attack. Rapid breathing, a racing heart, chest tightness, and a sense of dread are classic panic-attack symptoms. They are also classic PE symptoms. Patients who are young, female, or have any history of anxiety in their chart are at particular risk of having a clot attributed to stress.
• Pneumonia or bronchitis. A PE that damages lung tissue can produce a cough, a low fever, and a patchy spot on a chest X-ray that looks like an infection. The patient leaves with antibiotics that do nothing for a clot.
• An asthma or COPD flare. In patients with existing lung disease, worsening shortness of breath is easily blamed on the known condition — but medical references note that in these patients, worsening breathlessness may be the only sign of a PE.
• Musculoskeletal chest pain. Pain that is sharp and worsens with breathing or movement can be dismissed as a strained muscle or inflamed cartilage, especially if the patient mentions a workout or a cough.
• A “viral illness.” Fatigue, mild shortness of breath, and a fast pulse are written off as a bug that will pass.

Each of these conditions is more common than PE — which is precisely why the standard approach requires considering, and where the patient’s risk profile warrants it actively ruling out, the dangerous cause before settling on the benign one. In the diagnostic-error literature this is often called anchoring or premature closure: the clinician locks onto the first plausible diagnosis and stops looking. The pulse rate of 110, the oxygen saturation of 93 percent, or the knee surgery two weeks ago is noted in the chart but never connected to the question of a clot.

Risk Factors and Red Flags

Because the symptoms of PE are so nonspecific, emergency medicine generally places heavy emphasis on the patient’s risk factors. A 28-year-old with chest pain and no risk factors is a very different patient from a 28-year-old with chest pain who had a cesarean delivery ten days ago. Standard references describe blood clots as arising from three underlying conditions — sluggish blood flow, injury to a vein, and blood that clots more easily than normal — and nearly every recognized risk factor maps onto one of them. The ones providers are generally expected to ask about include:

• Surgery within the past month, especially orthopedic procedures such as hip or knee replacement
• A recent fracture, major injury, or hospitalization
• Prolonged immobility, including bed rest of more than three days or travel longer than about four hours
• Pregnancy and the weeks after delivery, including after a C-section
• Estrogen-containing birth control or hormone replacement therapy
• Active cancer or cancer treatment
• A personal or family history of DVT or PE, or a known clotting disorder
• Obesity, smoking, heart failure, and recent infection

Alongside risk factors, certain bedside findings are generally treated as signals that a clot must be considered: a resting heart rate above 100, oxygen saturation lower than expected for the patient, a respiratory rate that stays elevated, a patient who fainted or nearly fainted, coughing up blood, and swelling, tenderness, or warmth in one leg — the signs of a DVT, and among the strongest clues of all. Medical references also note that shortness of breath out of proportion to what a normal chest X-ray would explain, often called unexplained hypoxemia, should raise suspicion for PE.

None of these findings proves a clot. What they do is change the probability, and emergency medicine has built its approach to PE around that probability. When a provider documents a fast heart rate and low oxygen in a patient with a recent surgery and then discharges that patient with a diagnosis of anxiety, the question a malpractice review asks is not whether the provider could have known for certain, but whether a reasonably careful provider in the same position would have taken the next step.

What a Standard PE Workup Generally Looks Like

One reason missed-PE cases are so often litigated is that the diagnostic pathway is unusually well defined. Emergency physicians are not expected to scan every patient with chest pain, but they are generally expected to work through a recognized sequence of questions and tests.

Step 1: Estimate the probability. Providers generally use a validated scoring tool — most commonly the Wells criteria or the Geneva score — to sort patients into low, intermediate, or high probability of PE. The Wells score assigns points for signs of DVT, a heart rate above 100, recent surgery or immobilization, prior clots, coughing up blood, cancer, and the physician’s own judgment that PE is at least as likely as any other explanation.

Step 2: For low-risk patients, apply the rule-out criteria. The Pulmonary Embolism Rule-Out Criteria (PERC) is an eight-item checklist — under age 50, heart rate under 100, oxygen saturation of 95 percent or higher, no coughing up blood, no estrogen use, no prior DVT or PE, no one-sided leg swelling, and no surgery or trauma requiring hospitalization within the past four weeks. A patient who is low probability and meets all eight criteria generally does not need further testing. A patient who fails even one generally needs a D-dimer.

Step 3: D-dimer blood test. D-dimer is a byproduct of clot breakdown. A normal result in a low- or intermediate-probability patient is generally considered sufficient to rule out PE. An elevated result does not confirm a clot — many things raise D-dimer — but it generally means imaging is needed.

Step 4: Imaging. The definitive test is a CT pulmonary angiogram (CTPA), a CT scan with contrast dye that shows the pulmonary arteries directly. For patients who cannot receive contrast, or who are pregnant, a ventilation-perfusion (V/Q) lung scan or a leg ultrasound looking for DVT may be used instead. For high-probability patients, standard references generally call for proceeding directly to CTPA without waiting on a D-dimer.

Step 5: Treat. Once a PE is confirmed — and in high-suspicion cases, sometimes even before imaging is complete — the patient is generally started on an anticoagulant.

Where the Breakdown Typically Occurs

In missed-PE cases the failure is rarely a misread scan. More often a step in that sequence was skipped. Recurring error types include:

• PE never entered the differential. The chart shows no Wells score, no PERC assessment, and no documentation that a clot was considered, despite documented risk factors.
• PERC applied to the wrong patient. The rule-out checklist is used on a patient who was not actually low-risk, or who failed one of the eight criteria — for example, a 52-year-old or a patient on birth control.
• D-dimer not ordered, or ordered and not acted on. An elevated D-dimer is noted but attributed to something else, and no imaging follows.
• Reassurance from the wrong test. A normal chest X-ray or a normal EKG is treated as ruling out PE, when neither test can do that.
• Vital signs not reconciled with the discharge diagnosis. The patient is discharged with a diagnosis of anxiety while the last recorded heart rate is 115 and oxygen saturation is 92 percent.
• Discharge without return precautions or follow-up. The patient is not told what symptoms should bring them back, and no follow-up is arranged.
• Delayed treatment after diagnosis. The clot is found, but anticoagulation is not started promptly.

Each of these is the kind of step-by-step question a medical expert reviewing the chart will ask. Medical references have historically cited an untreated-PE mortality of up to 30 percent, compared with roughly 8 percent when treatment is started promptly — a gap that frequently becomes central to the causation analysis in these cases.

A Closer Look: How a Missed PE Plays Out

Consider a hypothetical, illustrative scenario: a woman in her early thirties arrives at an emergency room two weeks after knee surgery, reporting chest tightness, a racing heart, and shortness of breath that started that morning. Her heart rate is 112 and her oxygen saturation is 93 percent. A chest X-ray is normal, and an EKG shows nothing beyond a fast rhythm. She mentions she has been stressed about returning to work, and she is discharged with a diagnosis of panic attack and a recommendation to follow up with her primary doctor. Three days later she collapses at home, and a CT scan at a second hospital shows extensive clots in both lungs.

In a case like this, the review does not turn on whether a PE was certain at the first visit — it was not. It turns on whether the documented picture — recent orthopedic surgery, sustained tachycardia, low oxygen saturation — generally required the provider to score the probability, order a D-dimer, and image if it came back elevated before settling on anxiety. That distinction, between a genuinely reassuring clinical picture and a workup that stopped too early, is often the central question in these cases.

Blood Clots After Surgery and Childbirth

Not every PE claim involves a missed diagnosis in the emergency room. A second category involves clots that formed because a hospital failed to prevent them in the first place. According to the CDC, more than a third of VTE cases diagnosed each year are related to a recent hospitalization, most occur after discharge, and as many as 70 percent of healthcare-associated VTEs are considered preventable through measures such as anticoagulant medication or compression devices. The CDC describes VTE as a leading cause of preventable hospital death in the United States.

Hospitals generally assess every admitted patient’s clot risk and order prophylaxis — blood-thinning injections, compression stockings, or inflatable leg sleeves — when the risk warrants it. Patients undergoing hip or knee replacement, cancer surgery, or prolonged bed rest are among the highest-risk groups. When a patient at known risk receives no prophylaxis, or when ordered prophylaxis is not actually administered, and that patient develops a PE within weeks of discharge, the question is whether the hospital’s prevention protocols were followed.

The weeks after childbirth deserve particular attention. Pregnancy increases clot risk fourfold to fivefold, according to ACOG, the postpartum period carries the highest risk of all, and the risk is higher still after a cesarean delivery. Blood clots are consistently listed among the leading causes of maternal death in the United States, and ACOG has for years recommended compression devices during cesarean delivery, with anticoagulant prophylaxis added for women at elevated risk. A new mother who is sent home after a C-section and then returns to the emergency room short of breath presents a situation in which PE should generally be near the top of the list — and in which the two kinds of failure can overlap: a clot that might have been prevented, followed by a clot that was not recognized.

When a Missed PE May Be Medical Malpractice in Indiana

Not every missed PE is malpractice. Some clots present without risk factors or abnormal vital signs, and a provider who followed the standard pathway and reached a reasonable conclusion is not negligent simply because the outcome was tragic. A potential claim generally centers on whether the evaluation fell short of what a reasonably careful provider would have done with the same information, and whether that shortfall caused the harm. In Indiana, a missed-PE claim is generally evaluated under the same four elements as other medical malpractice cases:

1. Duty of care – The ER, urgent care, hospital, or treating provider had an obligation to evaluate the patient according to accepted standards of emergency medicine.
2. Breach of duty – The evaluation fell below that standard — for example, by failing to consider PE in a patient with documented risk factors and abnormal vital signs, or by discharging the patient without acting on an elevated D-dimer.
3. Causation – The missed or delayed diagnosis caused a worse outcome than the patient would otherwise have had. This generally requires expert testimony that timely anticoagulation would more likely than not have prevented the injury or death.
4. Damages – The patient suffered measurable harm, such as death, cardiac arrest with brain injury, chronic pulmonary hypertension, lost income, or pain and suffering.

Because emergency medicine is a specialized field, Indiana law generally requires testimony from a similarly situated medical expert to establish both what the standard of care required and whether the departure from it caused the harm. The records that expert will typically review include triage notes and vital-sign timestamps, nursing documentation, the physician’s documented differential diagnosis, any Wells or PERC scoring, lab results including D-dimer, imaging orders and reports, discharge instructions, and the records of any return visit.

As with other Indiana malpractice claims, a missed-PE claim against a qualified healthcare provider generally must first be submitted to the Indiana Medical Review Panel before a lawsuit can proceed in court. Indiana’s Medical Malpractice Act also caps the total damages recoverable in a qualifying claim — $1.8 million for acts of malpractice occurring after June 30, 2019 — with the provider responsible for the first $500,000 and the Indiana Patient’s Compensation Fund paying the remainder up to the cap. Claims under the Act are generally subject to a contributory negligence standard, which can bar recovery if the patient is found to have contributed to their own injury; a hospital’s defense may argue, for example, that the patient waited too long to return after symptoms worsened — which is one reason a careful, well-documented account of when symptoms changed and when care was sought generally matters as much as what happened at the visit itself, and why a patient who followed the discharge instructions they were actually given is in a very different position from one who ignored explicit warnings. These rules are technical and fact-specific and are best evaluated by an attorney reviewing the full record; see our article on how much an Indiana malpractice case may be worth.

The statute of limitations for a medical malpractice claim in Indiana is generally two years from the date of the alleged malpractice — in a missed-PE case, usually the visit where the diagnosis was missed, not the later visit where it was found, although Indiana courts have recognized narrow, fact-specific exceptions where the malpractice could not reasonably have been discovered within that window. Other exceptions exist as well: claims for children injured before age six may generally be filed until the child’s eighth birthday, and claims involving government-employed providers can carry much shorter notice deadlines. Because these deadlines are unforgiving, consulting an Indiana medical malpractice attorney early is the best way to protect the claim.

What to Do If You Suspect a PE Was Missed

If you or a family member were sent home from an emergency room or urgent care and later diagnosed with a pulmonary embolism, the first priority is medical: make sure the clot is being treated and that follow-up with a specialist is arranged. From there, a few steps can help protect your health and preserve your ability to have the earlier visit reviewed.

Request the complete records from the first visit, not just the discharge summary — triage notes, vital signs with timestamps, nursing notes, lab results, imaging reports, and discharge instructions. An attorney can obtain and organize these records, and hospitals are generally required to provide them on request. Write down the timeline while it is fresh: when symptoms started, what you told the staff, what tests were done, what you were told the diagnosis was, and what happened afterward. If a loved one died, the death certificate and any autopsy report are generally central to the review, since autopsy is often how a missed PE is confirmed.

Then consider speaking with an experienced medical malpractice attorney. Whether a missed PE reflects a breach of the standard of care is a question that generally requires a medical expert’s review of the full chart, and Indiana’s Medical Review Panel process and two-year deadline make early evaluation important. For more general guidance, see our article on what you should and should not do if you suspect medical malpractice.

Frequently Asked Questions

Can I sue if the ER sent me home and I later had a pulmonary embolism?

Possibly, but a bad outcome alone is not enough. The question is whether the evaluation at the first visit fell below the standard of care — for example, by not considering PE in a patient with documented risk factors, or by not acting on an elevated D-dimer — and whether that failure caused harm that timely treatment would likely have prevented. An attorney can have the records reviewed by an appropriate medical expert.

Why was my pulmonary embolism diagnosed as anxiety?

The symptoms overlap almost completely, and anxiety is far more common than PE. The concern in a malpractice review is not that anxiety was considered, but whether PE was considered and reasonably excluded before discharge — particularly where the chart documents risk factors such as recent surgery, hormone use, pregnancy, or a prior clot.

My loved one died of a blood clot days after surgery. Is the hospital responsible?

It depends on what the hospital did to prevent it. If a high-risk patient received no prophylaxis, ordered prophylaxis was not given, or symptoms before discharge were not acted on, those are the failures an expert review would examine. Such a claim may be brought as a wrongful death action under Indiana’s Medical Malpractice Act.

How long do I have to file in Indiana?

Generally two years from the alleged malpractice, with exceptions for young children and for government-employed providers. Because the Medical Review Panel process must generally be completed first, consulting an attorney well before the deadline is important.

What tests should have been done?

For most stable patients, the standard pathway is a probability score (Wells or Geneva), the PERC rule-out checklist for low-risk patients, a D-dimer blood test where PERC does not apply, and a CT pulmonary angiogram if the D-dimer is elevated or the probability is high. A chest X-ray and an EKG are routinely ordered but cannot rule out a PE on their own.

What compensation is available?

Damages in a qualifying Indiana claim may include past and future medical expenses, lost income and earning capacity, and pain and suffering; in fatal cases, wrongful death damages may be available to surviving family members. Indiana’s Medical Malpractice Act caps total recovery in qualifying claims — currently $1.8 million for acts occurring after June 30, 2019 — with part of that amount potentially paid by the Indiana Patient’s Compensation Fund.

Conclusion

A pulmonary embolism is dangerous precisely because it hides inside ordinary complaints. Emergency medicine has answered that danger with a clear, well-validated pathway — risk scoring, rule-out criteria, D-dimer, and CT angiography — designed to catch the clot before the patient goes home. When that pathway is followed and a clot is still missed, the outcome may be tragic without being negligent. When the pathway is skipped in a patient whose chart documented the very risk factors and vital signs that should have triggered it, patients and families have the right to have that decision reviewed.

If you or someone you love was diagnosed with a pulmonary embolism after being sent home from an Indiana emergency room, urgent care, or hospital, don’t wait to have the case reviewed. Speak with an experienced Indianapolis medical malpractice attorney to understand your options.

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The Powless Law Firm is an Indiana law firm that represents victims and families statewide in serious cases involving medical negligence, nursing home neglect, birth injury, personal injury, and wrongful death. If you have concerns about medical malpractice, please contact us at (877) 769-5377. Together we can make a difference.