The Doctor’s Advocate | First Quarter 2018
An Ounce of Prevention

Nurse Practitioner Closed Claims: Risk Mitigation Strategies

Our Nurse Practitioner Closed Claims Study, highlighted in this issue’s Director’s Forum column, reveals the major allegations and factors contributing to patient injury in 67 claims against nurse practitioners that closed over a six-year period. 

— Darrell Ranum, JD, CPHRM, Vice President, Patient Safety and Risk Management

The following strategies can assist NPs and physicians in preventing some of the injuries identified in the study:

  • Collaboration agreements, if applicable, should outline circumstances that require the NP to refer patients to the physician or seek a second opinion. Agreements should include a description of the level of supervision that will be exercised by the physician, including the number and frequency of chart reviews and cosignatures.
  • NPs and their physician partners must agree on the NP scope of practice based on the laws and regulations specific to that state.
  • The most common patient allegation in claims filed against NPs and physicians in FM and IM was failure or delay in diagnosis. In this study, the most common factor contributing to patient injury was inadequate patient assessment.
  • Complete a thorough clinical history and physical examination for each patient.
  • The ability to engage patients and obtain accurate histories is essential when developing a differential diagnosis.
  • Physicians, NPs, and office staff should take the time to explore patient complaints, especially when similar complaints are made on return visits.
  • Some diagnostic errors occurred when patients presented multiple times with the same or worsening symptoms.
  • If there is uncertainty about a diagnosis or about the appropriate testing to establish a diagnosis, the NP should ask the supervising physician to evaluate the patient.
  • Some diagnoses were overlooked when patients with chronic illness presented for treatment on multiple occasions.
  • Clinicians should consider new and unrelated illnesses when patients with chronic illnesses present multiple times for treatment.
  • A significant number of patients with coronary ischemia present with atypical symptoms or are younger than expected.
  • Thoroughly evaluate all age groups of patients presenting with chest pain.
  • On occasion, NPs and their physician partners failed to identify complications from surgery in post-op patients. Although uncommon, DVT, PE, compartment syndrome, peritonitis, and wound infections are outcomes that represent serious threats to patients’ well-being that may be difficult to diagnose.
  • Train office staff to recognize complaints from patients or families that warrant immediate follow-up. Allocate office time to seeing patients with fever, bleeding, shortness of breath, and pain who may be experiencing complications of surgery or other invasive procedures. Direct patients with potentially serious conditions to an ED for immediate care.
  • Documenting telephone conversations not only serves to provide information for other clinicians, but it can also be used to demonstrate that appropriate steps were taken when establishing a differential diagnosis.
  • Document the details of telephone calls, including any recommended follow-up.
  • Patients do not always follow physician or NP instructions for getting laboratory tests, imaging studies, or referral consultations. A tracking system will alert staff, NPs, and physicians when test results have not been received.
  • Have a clear policy and procedure in place for tracking diagnostic test results and referrals and verifying that reports are received and reviewed.
  • Patient compliance is a major problem, especially when patients don’t understand discharge instructions or fail to receive adequate instructions.
  • Use read-back or repeat-back techniques to confirm that patients understand discharge instructions, follow-up care, and medication plans. This form of interaction enables NPs and physicians to identify failures in communication between the patient and provider.
  • Patient behaviors were a factor in the outcome of care in 30 percent of NP claims and 29 percent of physician claims.
  • Document patient nonadherence to treatment plans, medication plans, and follow-up appointments.
  • Responses to a question about a patient’s intentions to follow instructions or purchase medications may provide clinicians with an opportunity to evaluate the patient’s level of understanding and to learn about affordability concerns.
  • Provide a list of community resources that can help the patient receive needed treatment and services if he or she has a limited ability to pay for medications, diagnostic tests, or follow-up appointments.
  • Informed consent is the responsibility of the clinician performing the procedure.
  • A physician cannot delegate responsibility for obtaining informed consent to an NP if the procedure will be performed by the physician. The NP (and RNs) can, however, assist with answering questions and ensuring the informed consent form is signed.

Implementing these strategies can help physicians and NPs provide the safest possible patient care.

For more patient safety and risk management resources, visit A patient safety risk manager is always available to provide industry-leading expertise. For more information, contact us at 800.421.2368 or by email.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

First Quarter 2018

Director's Forum
Nurse Practitioner Closed Claims Study

An Ounce of Prevention
Nurse Practitioner Closed Claims: Risk Mitigation Strategies

Government Relations Report
Damage Limits Protect Access to Healthcare

Training for Practice Managers and Other Staff

Foundation News
Foundation Grant Improves Hospitalist Communication

Innovations in Patient Safety
Leveraging Cardiology Data to Improve Care

The Back Page
Industry and Company News

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