To Mitigate Negligence Risks, CRNAs Must Adhere to Standards of Practice—and Document the Story of Their Care

Many certified registered nurse anesthetists (CRNAs) worry about what will happen if they are reported to the National Practitioner Data Bank (NPDB), but because the reporting process and its implications are often misunderstood, some of these worries may be unfounded. Understanding more about the NPDB can allay CRNAs’ potential concerns about their professional prospects.

Meanwhile, when CRNAs adhere to best practices in both care provision and documentation, they mitigate the risks of adverse events for patients. They also minimize their own liability hazards, because these same modes of practice and documentation may help prevent a CRNA from facing an allegation of negligence, and perhaps keep them out of an NPDB report, should an adverse event occur in spite of best efforts.

How Understanding the NPDB Can Allay Career Fears

When CRNAs are named in a malpractice claim, they may wonder, “What is this going to do to my career?” The answer depends in part on the nature of the report.

The NPDB was created to protect the public from unsafe providers who might travel across state lines and continue unsafe practices. It catalogs practitioners who have experienced a reportable event—but not all reportable events indicate malpractice.

When a patient is harmed, if they seek legal representation, a CRNA may find themselves included in an allegation of medical malpractice simply because their name is on the chart and they have malpractice insurance. The legal process of discovery, including interrogatories and depositions, then uncovers who was actually involved in the care.

While this process may take a year or more—and while simply being named in an allegation is stressful—during that fact-finding process, the CRNA could be removed from the case, and they might not be reported to the NPDB.

When a practitioner is named in a report to the NPDB, they may find that events have not been accurately described—and unfortunately, the practitioner can’t simply contact the data bank to correct the record. Practitioners can contact the reporting entity and ask them to correct their report or remove it, but that reporting entity may or may not do so, and in the meantime the provider is in the data bank.

A credentialing board has to query the national practitioner data, so for the rest of the CRNA’s career, every time they change jobs or are recredentialed, they may have to explain why they appear in the NPDB. That said, depending on what happened, their appearance in the NPDB might not be so impactful. Many reports are explainable and do not, on closer inspection, reflect poorly on the CRNA’s care.

Let’s say that a CRNA was named in an event in which a patient fell off the table—but the CRNA wasn’t yet in the room. In this situation, the credentialer’s experience comes into play. A credentialer with six months’ experience may flag the practitioner in ways that create stress during a job application process. On the other hand, a credentialer with a decade’s experience may look at the practitioner’s CV and speak to the CRNA early on. They may more quickly understand that the report has little bearing on the practitioner’s qualifications.

When it comes to insurability, since a report to the NPDB does not necessarily reflect risks associated with the practitioner, such a report does not by itself render a clinician uninsurable. Premiums may or may not increase.

The more healthcare professionals learn about the NPDB, the more they realize that a report does not by itself reflect badly on a practitioner’s quality of care.

How CRNAs Can Practice—and Document—to Protect Patients and Themselves

Over years as an expert witness, I’ve seen how, even when undesirable outcomes occur, adherence to standards of care and standards of practice, paired with best practices in documentation, can protect CRNAs against allegations of negligence.

Stay Abreast of Changing Practice Standards and Facility Guidelines

The things that help your patient also help you, and help your boss, and help your attorney defend your practice, if something goes wrong in spite of best efforts:

1. Follow standards of practice: Adhere to standards—the current standards. Evidence-based care requires ongoing reading and education to stay abreast of developments relevant to our specific practice environments. For instance, for MRI-type anesthesia (or cases outside of the operating theater), you may not be expected to know about the latest on-pump, off-pump procedures of cardiac anesthesia, but if you’re taking care of coronary artery bypass grafting (CABG) patients, you would be expected to know on-pump and off-pump protocol.

Our commitment to standards includes a commitment to vigilance against the “normalization of deviance”: Under production pressure and through sheer force of habit, as the authors of a recent study show, CRNAs can gradually succumb to the temptation to accept what should be unacceptable. One classic example is proceeding into surgery with an incomplete preanesthesia assessment. Another is proceeding with a monitor known to be faulty. We can easily imagine how an anoxic brain injury (secondary to lack of detection of inadequate ventilation) could result from this—and it has. If we then imagine attempting to explain such a practice during a deposition, we will swiftly realize that we never want to be in this situation.

2. Follow facility guidelines: Be aware of and follow the specific practice guidelines of your facility, because these also may change. Further, different facilities in a large hospital system may follow different bylaws and practice norms. If those practice norms are published in a handbook, and you didn’t follow them, that would put you on the wrong side of a claim.

Document the Story of Your Care

When I offer an expert opinion on a malpractice case involving a patient death, I start with the autopsy. I can see some of what the CRNA did—but it’s better if their charting explains it, because when we point and click (using electronic health records) to attest that we’ve done something, narrative information is often omitted.

For instance, let’s say the patient’s blood pressure dropped to 40, and the CRNA gave phenylephrine, saw no response, then gave epinephrine and called for help. That event involves narrative that they would want to put in the chart. The autopsy will show that all those medications were given, but without their narrative, if there’s nothing in the chart but point-and-clicks, the expert reviewer may be asking themselves, “Well, the metadata says the blood pressure went down over four minutes. What happened?”

Here’s another example: If the patient has some decrement in their saturation, and if you click that you’ve entered the room and you’ve done your check, and then the next thing you click is that they’re intubated and you’re ready to start surgery, then there are events that have happened in between that the monitor has captured on metadata, but that you have not explained, and this could prove detrimental.

A CRNA’s documentation has to tell the story of their care, including medications that they’re giving, why they’re giving them, and any reaction that the patient had. Documentation can make the difference between a credible allegation of negligence and a demonstration that the patient’s poor outcome was not due to CRNA negligence. Documentation that narrates a CRNA’s adherence to standards can stop a potential negligence claim in its tracks.