Discharged At Own Risk

I had my first case of discharged at own risk today. The patient came in for vomiting for investigation sometime after 12 noon. Upon arrival at the ward, the admin staff showed her to the room. Then the in-charge and admin staff quickly arranged for the AXR to be done stat. HCA K sent the patient down for the AXR. As I was busy with my medication rounds, I did not note the exact time of patient's arrival at the ward and return from AXR.

At 1:10pm, the specialist reviewed the patient at the ward, wrote up the IMR and left. Around 1:20pm, I reviewed the IMR and noted the specialist's orders. Domperidone suppository was ordered. As the ward admission interview was not done yet, I did a quick check with the mother on the child's condition. She was carrying the child and walking up-and-down the corridor and talking on her mobile. The mother replied quickly that the child had vomited once before admission, but not since. Then she looked somewhat unhappy to be interrupted and went back to her phone conversation. Seeing that the mother was busy and not wanting to be interrupted on her phone, I explained to the mother that we will not give the child the suppository yet. That was my mistake in my judgement.

Around 2:20pm, the child vomited. The mother called the specialist to complain that we had not done any intervention for her child since her arrival 2 hours ago. At 2:30pm, the specialist called up and instructed me to give the supp Domper stat, which I did immediately. As the shift handover report was in progress in the treatment room, SSN Y who was in-charge in that afternoon instructed that I only call the MO to follow-up with the IV cannulation after the shift handover report was done. When the shift handover report was done around 2:40pm, SSN Y arranged for the IV cannulation to be done by the MO. Meanwhile, the afternoon staff interviewed the patient for ward admission.

At 3pm, before the MO arrived for IV cannulation, the mother came to the nurses' station and demanded to be discharged. I called the specialist for his agreement on the matter, the medication for discharge and his fees. Meanwhile I had a hard time searching for the AOR form, so SSN Y helped me. Although we received the X-ray report via fax, we had not received the X-ray film yet. The admin staff called X-ray department to ask for their delivery of the X-ray film, but their porter was overloaded too. It was around 3:30pm when we received the patient's admissions record (with the patient's ID stickers) from the admissions department. It turned out that the mother only registered her child's hospital admission at around 1:30pm.

We quickly did the billings and documentation labelling for this patient. While we were doing so, the specialist came round for a second visit. SSN Y, as the in-charge, accompanied the specialist for his round. The specialist returned and signed the required IMR and billing papers. Then SSN Y sent the afternoon runner SEN MY down with the relevant documents for the pharmacy and the billing office. According to the specialist, the mother is herself a staff nurse at a restructured hospital. She is also a friend of our ward staff SN J, who was not on-duty today. This is really strange to me, because as an SN herself, she should know the workings of a ward and the priorities of investigations/interventions.

It was almost 3:50pm. The NO returned from her meeting and the admin staff updated her of the AOR discharge. The NO said that from the way the patient's mother was on the phone almost all the time since arrival at the ward, the NO suspected that her claims of a 2 hour delay in intervention was not the main reason for her AOR discharge request. Anyway, the NO went to talk the mother for service recovery. According to the NO, the patient's mother was about to start complaining when her husband signalled for her not to. They even rejected removal of Emla cream from the child's hands. When the NO returned, she instructed me to remove the Emla cream which I did, stopping them as they exit along the ward's corridor to do so.

In the end, the NO reviewed the case with me. She instructed me that in future, for new admissions, always give the medication first to avoid such claims of no interventions done. Fortunately, my colleagues had sent the child for AXR which was completed with report, in-time for their discharge. Thus the mother's claim of "no intervention done" does not hold water. Later, SSN Y advised me that if I was too busy to handle admissions in future, I should seek the NO's help. Lessons learnt.