The lessons we learn can come from our own experiences or those of others. In the case of risk management, closed malpractice claims provide a particularly valuable source of information. This includes aggregation of data and objective case studies, from which review and analysis can occur.

The delivery of primary care services has been undergoing an evolution — that includes shifting the use of nurse practitioners (NP). The Doctors Company, a medical malpractice organization, has taken note of the changes and released a report on their analysis of medical malpractice allegations in closed claims against nurse practitioners. They also compared the NP findings to family practice and internal medicine physician claims for context.

The goal was to leverage their claims experience to identify risks and trends involving patient injury and safety. Clinical analysts drew upon multiple sources to gain an accurate and unbiased understanding of the events that lead to actual patient injuries and death.

The most common allegations for nurse practitioners were related to diagnosis (48 percent), medication (24 percent) and medical treatment (16 percent). The top diagnosis-related claims were myocardial infarction (9 percent) and (each 6 percent) colon cancer, breast cancer, lung cancer, pneumonia, pulmonary embolism/infarction and sepsis. Of the medication-related claims, 63 percent involved improper medication management, and 24 percent were due to ordering the wrong medication.

Although the NP claims analysis is statistically limited due to the numbers, the study does show that diagnosis-related and medication-related allegations are similar between nurse practitioners and primary care physicians. Medical treatment-related allegations are more frequent for physicians.

The key difference between the two is that NPs have lower claims frequency, and their medication-related and medical treatment-related claims have lower indemnity payments.

Image: The Doctors Company

When it comes to the frequency of claims, the study found that physician claims decreased and seem to have leveled off over a nine-year period. The number of claims frequency for nurse practitioners is relatively low, but there has been a gradual increase during the same period. The growing needs for primary caregivers and physicians focusing on those with complex management or diagnostic problems, means nurse practitioners will increasingly provide primary care services.

The study also includes valuable case reviews by clinical experts to humanize the data and put failures in assessment, communication, collaboration and decision-making into context. Key findings included:

• An allegation of failure or delay in obtaining a specialty consultation or referral often occurred when an NP managed a complication that was beyond his or her expertise or scope of practice (SoP).
• Alleged failure to perform and adequate patient assessment often occurred when an NP relied on the medical history or diagnosis in a previous medical record rather than performing a new comprehensive exam.
• Many NP malpractice claims could be traced to clinical and administrative factors:
  • failure to adhere to SoP
  • inadequate physician supervision
  • absence of written protocols
  • deviation from written protocols
  • failure or delay in seeking physician collaboration or referral

Nurse practitioners are experiencing the same challenges that lead to adverse events as physicians, and this report offers recommendations to limit risk and improve patient safety. The clinical and administrative factors identified could be remedied if the physician and practice run a quality program that monitors the practice of the NPs to ensure they provide care within the scope of their SoP — in compliance with their state’s laws and regulations.

The report also provides 13 other risk-mitigation strategies that can be used as a self-assessment checklist to identify opportunities for improvement by any practice that includes nurse practitioners.