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I agree with your analysis. The “study” is so flawed that its primary use is a teaching tool on lousy methodology. With the caveat that EDs quality of care vary from excellent to awful it should surprise no one that there are significant problems in many EDs independent of the amount of misdiagnoses and it's effect on survival. These include but are not limited to poor triage, absurd waiting times, lack of time or appreciating “red flags” that lead to misdiagnosis and less-than-optimal care, poor or even mistreatment of specific patient populations (e.g., chronic psychiatric patients who present with a possible acute medical issue such as possible delirium). The fundamental approach when evaluating a patient: “What could reasonably be occurring that requires an intervention to prevent death or significant morbidity” is often replaced by a cavalier: “ What benign diagnosis gets the patient out of the ED with a set of instructions they don't read or understand.

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