17
Fitzgerald Health Education Associates, Inc., August 2015 fhea.com
NPs
employed by hospitals often write
discharge summaries and discharge
orders. It is questionable as to
whether this organizational practice is wise when the
NP has not been closely involved in the patient's hos-
pital care. Nevertheless, NPs are asked to perform this
service and can find it difficult to refuse.
This case exemplifies the pitfalls of writing dis-
charge orders for surgeons when the NP has not been
involved in the day-to-day care of the patient.
Case
A 53-year-old man fractured his right ankle on the job
when a vehicle ran over his foot. He was treated in the
emergency department. Because there was no palpa-
ble pulse in the ankle, he had orthopedic and vascular
surgery the next day. In the month following surgery,
he had additional surgeries, wound debridement, and
negative pressure wound therapy. One month after
the accident his care was transferred to a plastic sur-
geon. Three months after the accident there was a
healthy bed of granulation and the surgeon performed
a split thickness skin graft. Afterwards, the patient was
on bed rest with negative pressure dressings for 5
days. The surgeon ordered heparin to prevent throm-
bosis. The patient accepted the heparin shots for a
week, but then refused an evening dose and the next
morning's dose. The records do not document that the
patient was informed about the risks of refusing hep -
arin. There is no note that the nurses informed the
plastic surgeon of the patient's refusal of heparin. The
patient was discharged with instructions to remain on
bed rest with bathroom privileges until he visited the
plastic surgeon a week later. A NP wrote the discharge
report and orders; the NP did not include an order for
heparin.
Two days after discharge, the patient went into car-
diac arrest and died. On autopsy the pathologist found
that the cause of death was bilateral pulmonary
thromboemboli caused by a deep vein thrombosis in
the left leg. The patient's family sued the NP, who ar-
gued that heparin is not completely effective in pre-
venting blood clots and that it was difficult to confirm
the age of the fatal blood clot, which could have oc-
curred prior to the hospital discharge.
The parties settled for $750,000.*
NP Firsts Avoiding Malpractice: A Case Analysis
The Pitfalls of Writing Discharge
Orders When Not Closely Involved in a
Patient's Care
Carolyn Buppert, NP, JD
Continued on page 19