What happens when you go to the hospital and the discharge instructions don’t match the conditions that brought you there in the first place?
That’s what happened to a client of ours—let’s call her Lisa— who went to a hospital because of a potential spinal cord injury that was causing a loss of sensation and paralysis in her extremities.
Emergency medical service personnel recognized her risk of a spinal cord injury, but once she was evaluated in an emergency room (ER), the ER doctor sent her home with the diagnosis of a back sprain. The odd part about that is Lisa hadn’t hurt her back, denied back pain, and CT scans of her back showed no problems.
I recently took the deposition of a trauma surgeon in Lisa’s pending medical malpractice case. I asked him how he thought the ER doctor could come up with a diagnosis based on the lack of evidence from physician and nursing exams, as well as diagnostic testing. The trauma surgeon basically said that sometimes they settle on a general diagnosis when they can’t put their finger on what’s really causing the problem.
This is sometimes called a diagnosis of exclusion.
A diagnosis of exclusion is one that a physician, nurse practitioner, or physician assistant settles on when they can’t come up with another explanation. Several peer-reviewed studies have found that women, and particularly women of color, are more often discharged with a diagnosis of exclusion than other people.
Lisa is an African-American woman. She was sent home with an incorrect diagnosis of exclusion, even though she had a spinal cord injury.
Another client of ours was also an African-American woman. She was sent home from a major academic Houston hospital with classic signs of an ischemic stroke. She had one-sided facial droop, motor weakness on the same side, and slurred speech (aphasia). A neurology resident discharged her and sent her home with an inaccurate diagnosis of exclusion: neurogenic disorder. That one basically means “it’s in her mind.”
Hospital discharge process
The standard of care requires the nursing staff to start discharge planning on the very first day of a hospital admission. This is done in conjunction with physicians and the medical team.
A key focus of discharge planning is to ensure continuity of care. It’s the responsibility of physicians ordering discharge, as well as nurses implementing the discharge order, to protect the patient from having a deteriorating condition after being sent home.
When it’s time to discharge a patient from the hospital, the ordering physician and nurse should have conversations with the patient and/or caregiver about the next steps. Patients should also go home, or to the next facility, with a packet of documents summarizing the care received during the hospital encounter or admission, follow-up instructions, prescriptions, and when to return to the hospital if things don’t go as planned.
It’s important to listen carefully to these discharge instructions and review the information presented. If it looks like an apples and oranges situation, speak up and ask questions. If the doctor’s gone, advocate for yourself with the nurse.
One of my favorite things about the nursing profession is the role of patient advocacy. Texas Board of Nursing Rule 217.19(5) provides that a nurse’s duty is to always advocate for patient safety. Under Rule 217.11, all nurses are required to clarify any order that the nurse has reason to believe is non-efficacious or contraindicated. Good nursing advocacy can include providing additional information to a physician related to a discharge order.
As a former hospital administrator, it’s my experience that nursing advocacy usually is not hostile. Experienced physicians and advanced practice providers (physician assistants and nurse practitioners) give due attention and consideration to nursing recommendations. It’s better for everyone involved, and particularly for patient safety, to resolve discharge questions and concerns before the patient is sent home.
If you’ve been seriously injured because of poor hospital, medical, or nursing care in Texas, contact a top-rated, experienced Texas medical malpractice lawyer for a free consultation about your potential case.
