For NPs, Diagnostic Risks Stand Out: Evidence-Based Strategies for Safety

Nurse practitioners (NPs) are members of the fastest-growing profession in the U.S. The complexity of their practice is also growing, and NPs face distinct risks related to both patient safety and professional liability. By learning from other clinicians’ experience, NPs and their teams can apply evidence-based strategies to improve patient safety and reduce liability exposure.

The Doctors Company has analyzed malpractice claims against NPs from loss years 2007 to 2023,¹ giving special scrutiny to the 348 claims that best lent themselves to analysis of their catalysts, called primary drivers. Within this set of 348 claims, injury severity was often significant: Almost half of the studied claims included patients with high-severity injuries, including the nearly 30 percent of claims that involved a patient’s death.

In the NP claims studied, one prominent theme stood out: More than 40 percent of the allegations involved diagnosis (failure to diagnose, delayed diagnosis, or wrong diagnosis).

Primary Drivers of Claims Against NPs

Primary drivers are contributing factors that were the main catalysts to the events that caused the major injury or assertion of negligence. (Claims may have more than one primary driver.) Overall, among the claims studied, more than half had primary drivers related to patient assessment, part of the diagnostic process. From the 52 percent of claims with primary drivers relating to patient assessment:

• 24 percent showed failure or delay in ordering a diagnostic test. Among such claims, the tests most frequently delayed or not ordered were blood tests (27 percent), x-rays (15 percent), CT scans (13 percent), and ultrasounds (10 percent).
• 22 percent showed failure to appreciate and reconcile signs, symptoms, and/or test results.
• 13 percent showed failure to establish a differential diagnosis.

Case Example for Patient Assessment: Failure to Diagnose Myocardial Infarction

A patient in their early 70s was seen by a family medicine NP for medication follow-up. The patient did not have an appointment, and the NP was behind schedule during a busy day. The NP reviewed medications and ordered refills. The patient’s spouse described the patient experiencing severe heart pain a few days prior, but the patient described the pain as mild and attributed it to anxiety. Although the office ECG was abnormal, the NP did not ask the patient for a more detailed description of the pain. The NP also did not document their interpretation of the ECG or their rationale for decision making. The NP did order a stress test and told the patient to go to the emergency department (ED) if their pain continued or worsened.

Three days later, the patient presented to the ED with chest pain and altered level of consciousness. ED practitioners diagnosed an ST-segment elevation myocardial infarction, and during angiography, plaque broke off, causing a cerebrovascular accident with intracranial hemorrhage. The patient died the next day.

Experts were critical: The NP failed to recognize the significance of chest pain with an abnormal ECG. The patient was unmistakably experiencing a myocardial infarction at the time of the NP visit, so the failure to send the patient immediately to the ED represented a significant clinical error. Further, the NP failed to document either an ECG interpretation or the rationale for their clinical decision making.

Liability Risks in Claims Against NPs

In the case described above, the NP’s failure to direct the patient immediately to the ED was an example of a delay or failure to obtain a consult. When this primary driver was present in the claims studied, it resulted in a paid indemnity more than half the time. (An indemnity is a sum of money paid to a person in compensation for damages or losses they have incurred or will incur related to a specific accident, incident, or event.)

The case described above also featured insufficient documentation. Again, in the NP claims studied, where this primary driver was present, a paid indemnity was present more than half the time.

Risk Mitigation Strategies for NPs

NPs can wield the power of the pause. Pausing before decision making reduces high cognitive load, prevents decision fatigue, and improves judgment quality by allowing the clinician’s thoughts to reset and move away from automatic, biased responses.

1. Take a diagnostic time-out: Even in the absence of a structured team time-out process, any individual NP can maintain a mental habit of diagnostic time-out. NPs may also choose to share this habit with their care teams. A diagnostic time-out might consist of:

• Acknowledging the potential for cognitive bias within daily practice. The influence of cognitive bias is suggested by the overwhelming prominence of the primary driver of patient assessment, accompanied by the commonality of the primary drivers of failure to obtain a consultation/referral and communication among practitioners. Although cognitive bias can occur throughout the diagnostic process, its early phases are heavily laden with gathering, receiving, and processing information, making them especially vulnerable to reasoning flaws. Two common cognitive biases are (1) anchoring (clinicians may become overly attached to an initial diagnostic impression, to the point of refusing to alter course in the face of new, disconfirming information) and (2) availability (clinicians may be more likely to think of a diagnosis if it’s more available to their memory, perhaps because they’ve recently seen it in another patient).

• Asking: What else could this be?

• Asking: Am I following the differential diagnosis process? Did I start with a broad list of possibilities, and have I narrowed it down by reviewing the patient's history, exam, lab results, and other findings?

• Asking: Does this clinical scenario fall within my scope of practice? Would I be wise to consult or refer?

2. Document with structure: Compose clinical documentation using the SOAP note structure—subjective, objective, assessment, and plan—or follow some other formula that encourages both reflection and diligence. Capturing the narrative arc of the patient’s presenting concerns and the care provided protects patient safety, helps other clinicians, and reduces liability risk for the documenting practitioner. A habit of structured documentation helps busy clinicians avoid rushing through incomplete notes.

3. Document information and materials shared with patients: Follow up on diagnostic test results. Include how the results were shared with the patient. If you provide printed materials to the patient, include what was provided. The same goes for discharge or follow-up instructions.

4. Revise documentation drafted by an AI scribe: An AI tool may augment, but must never replace, clinical judgment. AI scribes may produce documentation significantly lower in quality than human practitioners, so clinicians must carefully review AI-drafted notes for accuracy, paying special attention to stated diagnoses, ordered labs, ordered medications, and prescribed doses.

NPs can apply evidence-based best practices to elevate patient safety and limit their liability exposure. These best practices include always performing a thorough patient assessment, establishing a differential diagnosis, carefully tracking test results, and, when appropriate, referring patients to a higher level of care.