My First Mistake as a Nurse Practitioner

Mistakes aren't cool in patient care.  In doing some research for this post, I looked up "mistakes" on Pinterest.  Immediately, my laptop screen populated with graphics covered in hearts and swirls and all colors of the rainbow saying things like "Mistakes are sometimes the best memories".  Well, let me tell you, the mistakes I have made in my career as a nurse practitioner are not my best memories.  They are not glamorous learning experiences.  With these mistakes, there is an actually human being on the receiving end.

My first mistake came early on in my career as an NP.  It was a busy day in the clinic leaving me to see patients largely on my own.  I worked alongside a physician, another NP and a PA.  But being that our clinic focused on billing, helping me out meant financial sacrifice on the part of my coworkers- they couldn't see as many patients and wouldn't make as much money if they spent time answering my questions.

My next patient was a 50-something year old man with abdominal pain.  Palpating his belly, I knew something was potentially wrong.  He was tender and guarded when I pressed on his abdomen.  While his symptoms could certainly be related to a simple case of gastroenteritis, I suspected something more serious.  Not entirely sure what to do- I didn't want to send him to the ER unnecessarily, I consulted my supervising physician asking her to examen the patient as well.  

She was too busy to see the patient herself, but recommended he go next door for an outpatient CT scan.  I would call the radiologist so his scan would be read immediately.  This way, if everything checked out OK he could avoid the more expensive and time consuming option- going to the emergency room down the street.

I explained our plan to the patient, expecting him to readily agree, but instead was met with resistance.  He did not have insurance  He did not want to pay for a CT scan.  At this point, I recommended he go to the emergency department where his payment would not be collected up front.  He declined.  

I went back to consult my supervising physician.  Although distinct, his abdominal tenderness was mainly epigastric.  He had vomiting and diarrhea.  Based only on my minimally experienced word of mouth (she had still not examined the patient), the physician suspected he may have a case of diverticulitis.  She suggested I place him on antibiotics with close follow-up instructions. 

My initial impressions of this patient were correct.  He got worse throughout the day and presented to the emergency department that evening with an appendicitis.  Feeling that he was misdiagnosed at the clinic that afternoon, he hired an attorney with the intent to sue me.  Awesome.  I was about to be sued for malpractice two months into my nurse practitioner career.  

The case held no legal recourse and never really got off the ground.  I had documented our entire interaction, including that I had recommended both a CT scan and that he visit the emergency department, saving my behind.  While I didn't technically make a major mistake- the patient didn't have a poor outcome and I had recommended the appropriate diagnostic procedure, I may have been able to express my concern to him or diagnose him with greater certainty without imaging now that I have more NP experience under my belt.  I should have insisted that my supervising physician come examen the patient herself.  I wasn't confident in my abilities at this point in my career and needed a more experienced provider's opinion. 

Mistakes happen in medicine.  If you are a new nurse practitioner (or even a seasoned one), be careful out there.  If something doesn't seem right, get a second opinion.  Ask for help when you need it, taking risks isn't worth it.  If you have a question and other providers available to help, ask them to physically see your patient in question.  This way you will learn more.  Always, always document in detail your discussions with patients, especially when they don't take your medical advice.  This way, if something goes wrong there is a record of your interaction. 

Thankfully, my first misdiagnosis didn't result in a poor outcome and served as a learning experience. 

 

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Comments

But would he sue you or the doctor?? in addition, there are specific signs that could indicate appendicitis, you are a nurse practitioner so I do not see why you could not admit him if you sensed something was wrong. I think that when a doctor is busy and cannot come see the patient, the person who is able to assess is the one who should provide with the clues that will lead to a diagnosis.

Mary