Sixty-four cases of missed myocardial infarction in the emergency room were identified from the records of a major insurance company. The records were reviewed by three health care professionals using established standards of care for myocardial infarction. The diagnosis of myocardial infarction was missed in many cases due to the lack of diagnostic test ordering, poor interpretation of diagnostic tests, and the young age of the patients. Most patients were presented with symptoms compatible with myocardial ischemia. There was an 83% mortality rate in the 64 cases. The cost of settlement and litigation far exceeded the cost of safe, effective, medical care in the cases studied.