8 September, 2018
I’ve been working independently as a PNP for 3 years now and I think I’m getting pretty good at it. I have a panel of 600 patients and see some 16-20 families every day. I pride myself in getting thorough histories and providing holistic care.
Today I made a mistake. It wasn’t my first and it won’t be my last. It’s frightening when it happens. I am responsible for keeping my patients healthy, but when I am not at the top of my game, I put someone’s life in danger.
I wanted to write about this now, while it’s still fresh, so I can learn from it and hopefully help others avoid making the same mistake.
Today’s lesson: READ ALL THE VITALS!
A 7 day old term infant is brought by her mother for a follow up weight and bilirubin. I just saw her yesterday for her newborn check and she was 14% under birthweight (you get worried if it’s more than 10%), her bili was at High Intermediate Risk for neurotoxicity. This first-time Mom had just gotten the hang of breastfeeding. I called the NICU to see if I should admit her, but they said I could monitor her outpatient. Today her weight was up 50g from yesterday and her bili was downtrending. It looked like baby had turned the corner. Mom was very proud of herself for waking baby up every 30minutes and exclusively breastfeeding. I did a quick heart and lung check, looked at baby’s color and sent them on their way, with a follow up in 4 days. After sitting down to document my visit some 5 minutes later, I saw that baby’s temperature was 94.8. Oh shit. I ran back to the room. Mom and baby had left. I thought about deleting the temperature- with the following excuses: “temp was normal yesterday, we really didn’t need to get one today,” “the medical assistant is new, it was probably an error.” I thought about it for another minute and decided to call mom to come back for a recheck. Of course her phone is off. I find another number for her- also off. I leave a message and decide to call back in an hour- give her time to get home and charge her phone. Phones are still off. It’s 4pm and I have one last option to get ahold of them. I ask our transportation director to do a home visit and ask them to come in. He goes, and calls me so I can explain to dad why they need to come back. I tell him that his baby’s temperature was recorded as very low today and it needs to be rechecked. I told him if it is really that low, it could be a sign of infection and they will need to go to the hospital for further evaluation. Dad agreed to come in. They never showed. Mom and dad’s phones stayed off. I had to come home today not knowing if this baby is septic or if the new MA made an error taking the rectal temp.
All because I didn’t read all the vitals before seeing my patient. How basic is that! I used to take plenty of vitals and always found that part of the job to be particularly enlightening. Vitals are data. They can point your assessment and differential. Had I seen that temp before entering the room, I would have done a full exam. I can’t be sure from today’s cursory exam that my patient was not septic. Baby was yellow and sleeping. I didn’t wake her up, or check her liver, or her tone. Now I also regret not setting up a follow up for tomorrow. I set it up for 4 days because that’s when I work again and didn’t want to burden the other providers with a weight check (really?). What do they say about hindsight being 20/20? Well I can clearly see that I made several mistakes at this visit. I can only hope that the parents decide to bring the patient back for a recheck and everything is fine.
Everyone makes mistakes