Nurse Practitioners and Medical Malpractice
CASE STUDY WITH RISK MANAGEMENT STRATEGIES
Presented by NSO and CNA Medical malpractice extends to every healthcare profession including nurse practitioners. As nurse practitioners assume an expanded role in the healthcare industry, related legal issues increase. As a result, nurse practitioners are more frequently being named in medical malpractice litigation. According to CNA HealthPro’s and NSO’s 2009 nurse practitioner claims study encompassing ten years of nurse practitioner claim data, over $64.8 million was paid for medical malpractice claims on behalf of nurse practitioners.* Case Study: Failure to Assess Resident and Failure to Inform
the Physician of Resident’s Unstable Condition
Mediated Settlement Payment: $450,000 Legal Expenses: $181,225 Note: There were multiple co-defendants in this claim who
to 8:00 a.m. to the nurse practitioner. The nurse practitioner
are not discussed in this scenario. While there may have been
was also expected to make resident visits as needed to assess
errors/negligent acts on the part of other defendants, the case,
comments, and recommendations are limited to the actions of
On day one of the case, the nursing home physician ordered
the defendant; the nurse practitioner.
that the resident be started on Bactrim for a bladder infection.
This case involves the treatment and subsequent death of a
The nursing home staff correctly questioned the order, since
78-year-old female resident of a nursing home. She had a
Bactrim has the potential to adversely react with the blood
number of medical conditions including hypertension, chronic
thinner Coumadin but the nursing home physician continued
anemia, chronic renal failure, congestive heart failure and
the order. The resident also took daily doses of ibuprofen for
morbid obesity. She was prescribed the anti-coagulant drug
pain which may further increase the risk of bleeding. On day
Coumadin because of atrial fibrillation and the related risk of
two, the resident’s laboratory test results showed no bladder
infection, however, the Bactrim was not discontinued.
The nursing home physician (who was also the president and
On day six, the resident’s laboratory tests showed that her
medical director of the nursing home) contracted with a
bleeding time had increased and that she was at risk of bleeding
physician-owned healthcare staffing agency where the
from the Coumadin. Documentation is unclear whether any of
physician owner was also the agency’s medical director. The
the three practitioners were notified of the resident’s increased
nurse practitioner defendant was employed by the physician-
bleeding time. On day eight, the resident began bleeding from
owned healthcare staffing agency and was assigned to the
her gastrointestinal tract. The nurse practitioner was notified
nursing home to provide telephonic on-call resident care
and provided orders to stop the Coumadin for two days and to
services, emergency telephone resident services and on-site
recheck the resident’s blood tests on day eleven. It was alleged
on day 10 that the nurse practitioner was notified by the
nursing home staff that the resident had blood clots in her
All three practitioners were involved in the case involving the
stools, but the nurse practitioner has no recollection of being
decedent plaintiff. For purposes of this discussion, the nursing
told this and maintained no documentation regarding the
home physician/president/medical director will be referred to
as the nursing home physician. The contracted staffing agency
physician-owner and medical director will be referred to and
The nurse practitioner stated that it was her custom and
the agency physician and the nurse practitioner defendant will
practice after each call from the nursing home, to fax her on-
be referred to as the nurse practitioner. The complex
call report for the nursing home physician to the nursing home
arrangement for the provision of resident services at the nursing
fax number. Since the nurse practitioner responded to resident
home is a significant contributing factor in the events leading
calls outside of normal business hours, it is reasonable to
assume that the nursing home physician would not receive the
fax until the next time he was physically present in the nursing
As noted above, the nurse practitioner was employed by the
home. The nurse practitioner stated that she did not keep
contracted staffing agency to provide on-call services to the
copies of the reports or her notes made during calls from the
nursing home and its residents. The nursing home physician
nursing home. The nursing home physician denied receiving
delegated the responsibility to respond to all patient care calls
the defendant’s faxed on-call reports.
from the nursing home staff on week day evenings from 5:00
p.m. to 10:00 p.m., on weekends from 8:00 a.m. to 10:00 p.m.
and for emergent pager calls during the week from 10:00 p.m.
The resident continued to bleed through days nine, 10 and
According to the defense team’s claim consultants, the nurse
11. The nurse practitioner and the nursing home physician
practitioner made a very credible witness. The defense team
were notified of the continued bleeding but neither modified
engaged numerous experts to defend her including a forensic
the resident’s care plan. The nursing staff notes reflect that
pathologist, gastroenterologist, toxicologist, hepatologist,
the resident was dizzy and nauseated but there is no evidence
physician and two nurse practitioners. The defense argued
that the chain of command was utilized to involve nursing
that the nurse practitioner was within the standard of care
leadership in obtaining treatment for the resident. The
when responding to a telephone triage call by ordering that
morning of day 11, the resident was found to have expired in
the Coumadin be discontinued for two days and ordering a
her bed. Subsequently, an autopsy was performed by the state’s
follow-up laboratory test of the resident’s bleeding time.
Medical Investigator’s Office with the determination that the
The plaintiff experts argued that the nurse practitioner
resident bled to death from a gastrointestinal hemorrhage.
should have obtained vital signs, medications, current
The daughter of the deceased sought damages and sued the
problem list, past medical history and laboratory studies. She
nursing home, the nursing home physician, the contracted
should further have stopped the resident's Bactrim and
staffing agency, the agency physician and the nurse
ibuprofen, identified her anemia and ordered ‘STAT’
practitioner. The allegations against the nurse practitioner
laboratory tests. If the nurse practitioner felt she did not have
a clear understanding of the resident's condition, she should
• failure to evaluate, monitor and treat the resident's
have ordered that the resident be transferred to the hospital
or she should have gone to the facility to personally examine
her. Plaintiff’s experts indicated that it was the nurse
• failure to timely contact the nursing home physician
practitioner’s responsibility to order and obtain the
information she needed to make an appropriate assessment
• exceeding her scope of practice by making medical
of the resident’s condition rather than to wait for
decisions about the resident’s bleeding
Resolution After two and one-half years, the claim against the nurse practitioner settled at mediation for $450,000, and an additional
$181,225 in legal expenses were paid. The physicians, nursing home and the staffing agency also settled the actions against
them at mediation. The amount of the additional settlements is not available. Risk Management Comments
The daily responsibility for the clinical care of this resident was fragmented among multiple practitioners. Accountability and
communication channels were unclear. It appears that the nursing home physician, agency physician and the nurse
practitioner all contributed directly or indirectly to the resident’s care at some point with no one professional acting as the
primary care provider with responsibility for the oversight of the resident’s unstable and rapidly failing condition.
The nursing staff identified the potential for adverse interaction of the resident’s medications but their concerns were not
heeded. There is no evidence that the nursing staff persisted through the nursing chain of command regarding their concerns
and the resident continued to receive the Bactrim and ibuprofen even after the Coumadin was discontinued.
The role of the dispensing pharmacist in this resident’s medication regime is unclear as the combination of medications had
obvious contraindications and should have been reported to the nursing home physician (ordering physician) and clarified
before being supplied to the nursing home by the pharmacist.
The nurse practitioner never actually visited the resident during the period in question. She indicated that she had faxed
information regarding clinical symptoms reported by nursing staff and laboratory findings for this resident to the nursing home
physician. However, the nurse practitioner retained no copies of the faxed documents and made no entries into the resident’s
health record. The nurse practitioner performed no follow-up actions to determine if the nursing home physician timely
received the faxed information in order to adjust the resident’s care accordingly. The nurse practitioner maintained no notes
related to her conversations with nursing home staff nor did she document her clinical decision-making process in any format.
The nurse practitioner failed to physically assess the resident, failed to actively seek out the results of laboratory tests and when
provided with clinical evidence of abnormal bleeding times and visible gastrointestinal bleeding, failed to order the resident’s
Without knowing the results of the claim against the additional defendants in this case, it would appear that many disciplines failed
to communicate effectively and that oversight for this resident’s care was not properly maintained by any individual practitioner. Risk Management Recommendations
The role and scope of clinical practice of a nurse practitioner in any clinical setting (whether employed or contracted)
must be clearly defined and understood among all involved parties including:
direct resident/patient care nursing staff
attending, consulting and contracted physicians
dispensing pharmacist and consulting pharmacist
The contract defining the responsibilities of nurse practitioners providing on-call coverage for resident/patient care
should specify under what conditions the nurse practitioner is allowed/required to visit the resident/patient rather than
Communication between the nurse practitioner and any other party regarding the resident’s/patient’s care is to be
documented in a pre-defined, consistent, confidential manner and retained where it is readily available to the members
Verbal and telephone communication must be timely documented in the resident/patient health record.
Each resident/patient must have an identified attending physician who is ultimately responsible for the overall clinical
decision-making in determining the resident’s/patient’s care and treatment.
On-call practitioners of all types should be required to physically assess a resident/patient in need if the attending
physician is not available and the resident’s/patient’s condition is unstable or deteriorating.
Practitioners of all types should be prohibited from faxing information without providing original documentation in the
resident’s/patient’s health record within 24 hours.
Practitioners of all types should refrain from providing orders and advice regarding complex or unstable
residents/patients without obtaining full information regarding the resident’s diagnoses, medications, response to
treatment and on-going clinical monitoring results. If such information is not readily available, the unstable
resident/patient should be transported to a hospital for acute and immediate care. Guide to Sample Risk Management Plan
Risk Management is an integral part of a healthcare professional’s standard business practice. Risk management activities
include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or
eliminating these risks - A good Risk Management Plan will help you perform these steps quickly and easily!
Visit www.nso.com/riskplan to access the Risk Management plan created by NSO and CNA. We encourage you to use this
as a guide to develop your own risk management plan to meet the specific needs of your healthcare practice.
*Understanding Nurse Practitioner Liability: CNA HealthPro Nurse Practitioner Claims Analysis 1998-2008, Risk Management Strategies and Highlights of the 2009 NSO Survey, CNA InsuranceCompany, December 2009. To read the complete study visit www.nso.com/NPclaimstudy2009
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