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Case: A Nurse's Role in Preventing Diagnostic Error

Despite almost two decades of attention and study, diagnostic error continues to be a main issue in healthcare, affecting an estimated 12 million people each year and causing harm in one-third of those cases.

The most comprehensive literature on this topic comes from “Improving Diagnosis in Health Care,” in which the first recommendation is to “facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families.” Specifically, it calls for increasing nursing engagement in the diagnostic process; the diagnostic process is no longer the sole purview of a physician. Here we use a case review to demonstrate the importance of nurses in reducing diagnostic error and saving patient lives.

Case Review

A 28-year-old male patient came to the emergency department (ED) with abdominal pain and nausea one week after being discharged for an abdominal surgery that included placement of an abdominal drain. Imaging was done in the ED; his surgical team decided to admit him and replace the abdominal drain the next day. He had spinal hardware, which made comprehensive imaging difficult.

The patient was admitted to the surgical floor, where he was well-known to the nursing staff from his prior admission. Once he was in his inpatient room, he rapidly went from walking and talking at entry to reporting feeling faint with a high level of anxiety. Vital signs were obtained, which showed tachycardia, hypotension, and hypoxia by pulse oximetry. A rapid response was called, and both the rapid response team and the patient’s surgical team entered the room and began troubleshooting what may be happening.

The patient turned to the nurse and told her: “My stomach…look at my stomach…it’s getting so big so fast.” The nurse immediately noticed that his stomach was rapidly enlarging and looked to the team to let them know. No team member addressed the nurse, however, other than to request that she hang fluids, obtain labs, and other tasks.

The nurse set about doing the tasks and assumed that with the number of clinicians in the room, the enlarged abdomen would be rapidly identified and may have already been noted. Meanwhile, the team worked up the patient for a potential pulmonary embolism and sepsis without asking the patient or the nurse what they were most concerned about.

The patient was transferred to the ICU shortly after the rapid response was called; he died within two hours of ICU admission from what was later identified as an abdominal aortic aneurysm (AAA). The AAA could have potentially been identified and acted upon sooner had the clinical team done an abdominal assessment, which would have revealed a pulsating, enlarged and tender mass.

The case was later discussed at a morbidity and mortality conference. None of the nurses from any of the units involved (ED, floor, ICU) were invited. The clinicians concluded that the missed diagnosis was due to the inability to get proper imaging related to the patient’s spinal hardware and the team failing to place AAA on their differential.

Case Discussion

The failure to diagnose does not happen in a vacuum. As is often the case, there were many factors that led to this failure to diagnose and possibly the patient’s death. It was not only the nurse who had a critical data point that may have led to consideration of an AAA; the patient and the patient’s mother both noticed the alarming changes in his abdomen. Even if neither had noticed, once the rapid response was called related to a change in the patient’s condition, some physical exam or reassessment should have been done. On exam, the change in abdominal status would have been apparent.

The communication issues were bidirectional: the nurse knew the finding was concerning and wanted the team to know, but she was not fully confident in her role or her duty to interrupt to ensure that the team knew about it when she had not been directly asked. The rapid response team and the surgical team had both asked the nurse to do tasks but had not asked her for her assessment of the patient.

The Nurse’s Role in the Diagnostic Process

The nurse has a responsibility to contribute to the diagnostic process. Anecdotally, this responsibility is sometimes misunderstood because of confusion over the state’s scope of practice laws regarding medical diagnosis. While some states (though not all) explicitly state that it is outside a registered nurse’s scope of practice to medically diagnose a patient, this does not erase the role of the nurse in the diagnostic process.

Assessing the patient and communicating findings to the medical team is absolutely within a nurse’s scope of practice, and there is substantial legal precedent demonstrating that nurses were held accountable when concerning findings were not identified and communicated. Communicating with the patient, understanding the patient’s concerns, and relaying those concerns to the medical team are also undoubtedly within the role of the nurse; these are all key components of the diagnostic process.

As mentioned, the nurse’s lack of involvement in the diagnostic process in this case was a bidirectional issue. The solution required is also bidirectional. The nurse needs to be aware that it is their role to share their assessment findings with the medical team. The medical team needs awareness that the nurse holds crucial information to the diagnostic process.

It is not a matter of the nurse needing to be particularly outspoken or confident. Performing an assessment and sharing those findings is as much a duty and a right for a nurse as administering ordered medications or obtaining labs, and this should be recognized by the entire medical team.




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