09 Jul Medical malpractice comments

Please reply to the two comments

1st comment

The scenario reviewed involves a 15-year-old female complaining of a severe headache. She also complained of stiff joints, aches, and fever. Her mother took her to the NP in the evening where the NP performed some functional tests to rule out meningitis and ordered some lab work. The NP diagnosed influenza but informed the mother to call if the patient vomited or any new symptoms arose. The mother phoned at 7pm that the patient was vomiting. This is where a critical error was made in referring the patient to remain at home for the night and to come into the clinic in the morning. By 9 am the next morning the patient was lethargic and marginally responsive. The clinic called 911 yet the patient ultimately died one week later with a brain herniation.  The four elements of malpractice that must be present are duty, maintain a standard of care, causation of injury, and the actual injury. A duty was established between the NP and patient during the first clinic visit. A relationship was formed in that moment. An NP must be held to standards of care that any prudent NP would adhere to. The standard of care was not upheld as the only definitive test for meningitis is a spinal puncture. The standard of care would have been a referral on to the emergency room for further testing. The remaining two elements are causation of injury and injury. The patient did have an injury from the meningitis of a brain herniation that led to death. However, the NP did not cause the injury directly. The injury was from a missed diagnosis on the part of the NP not malfeasance.

The take away from this example is follow through. When the NP warned the mother about vomiting occurring a plan needed to be in place of next steps to take if this scenario did arise. Also follow through on a referral to the emergency room would have stopped all of these mis-steps that accumulated in the death of a patient. By an NP having a solid plan, intervention, and follow up results/outcomes at each crossroads in the treatment of this patient the diagnosis would not have been missed and ultimately could have saved the patients life. The number one thing that an NP can do to avoid litigation is know what NPs can do in your state of practice (Scope of Practice). Having written protocols also avoids litigation. The main thing about written protocols is to make sure everyone has a copy and does not get so comfortable that they veer from the protocols (“4 steps for practices to reduce malpractice claims against nurse practitioners,” 2018).  In the scenario mentioned above a supervising pediatrician took a cursory look at this patient and did not make any of their own notes regarding the patient. Adequate supervision when needed of the NP is also a step that can be taken (“4 steps for practices to reduce malpractice claims against nurse practitioners,” 2018). For example, a patient with chest pain is always seen by the supervising doctor or referred to the emergency room. Some set of protocol standards need to be set for certain patient populations.

The trend for malpractice payments on the behalf of NPs is lower than physicians (Brock et al., 2017) However, diagnosis related malpractice allegations are higher for NPs than physicians (Brock et al., 2017). This shows that NPs need to take their time, truly listen to the patient, and make their educated diagnosis following protocols. In the scenario above, this NP follows right along with the malpractice trends of diagnosis allegations. The first missed diagnosis was in the first clinic visit when the patient was not sent to the ER for a lumbar puncture. The next set up for malpractice regarding diagnosis is after hours when the patient is reported to have vomited multiple times. The NP missed this referral once again on to the ER. It finally took the patient showing up in dire straits before the appropriate referral to the ER was finally made.

Second Comment

1. Give a brief summary of the scenario and identify which of the four malpractice elements were present, must be present, and why.

Example 2-

     A boy was not feeling well at school. His parents took him to the clinic where the boy described his pain and noted a recent sports injury. NP A prescribed medications and ice. Several days later the parents brought the boy back to the clinic with increased pain 10/10 and unable to walk. Tests were run showing abnormal CBC, CT, rash, adn tremor. An MD consulted on the case but notes were not made. The boy was referred to an orthopedist. The following day the parents took the boy to the hospital due to difficulty breathing and severe pain. The boy was found to be in septic shock and septic hip. He passed away after two months in the ICU (Buppert, 2018.) 

In this scenario the provider’s conduct fell below the standard of care by failing to:

• Document medications 
• Document negative findings 
• Assess cause of the rash 
• Assess and document the patients gate 
• Order tests to rule out sepsis 
• Order aspiration of hip after seeing notes from the radiologist on the CT

1. Offer strategies on how to avoid these constructs in your advanced practices.

     Malpractice elements include the NP owed the plaintiff a duty, the NPs conduct fell below the standard of care, the NPs conduct caused the plaintiffs injury, or the plaintiff was injured. If an NP is talking to a person in a social setting answering questions or providing advice on medical issues that person now has a relationship with the provider. The NP should exercise caution when discussing medical issues and provide the same guidance or advice they would provide with an established patient in an office setting. It is important to stay updated and practice within the standards of practice provided on a state and federal level. If there are particular standards of care guidelines used within your practice, agency, or system practice within these guidelines. If the NP is not confident or unsure of a decision, always be conservative. Rule out the worst case scenario early on in your assessment process to ensure you are providing the most thorough level of care. The NP should be aware of their scope of practice and practice within their scope and expertise. And finally, follow up with your patients. Patients get busy, dont prioritize their health, or possibly could have misunderstood their treatment plan in their visit. It is our responsibility to ensure our patients are thoroughly cared for and nothing falls through the cracks (Buppert, 2018). 

1. Finally, comment on the medical malpractice trends of Nurse Practitioners (see the article linked in this weeks readings) as it relates to these malpractice examples. What would a reasonable NP have done, in your opinion?

     The article examines malpractice trends among MDs, PAs, and NPs. The authors note that PAs and NPs were less likely to have made malpractice payments or adverse actions than an MD as well as the reason for malpractice payout was different. While PAs and NPs had less payouts than MDs, their payouts were more likely to have been to a diagnostic or treatment error. For the PAs and NPs malpractice payout related to diagnosis or treatment related events was 75% and for the MDs it was less at 50% (Brock et al., 2017). This is interesting in that diagnosis and treatment related events lead to the suit in example two of the young boy discussed above. The NP in the example failed to perform indicated assessments, diagnostic testing, and appropriate treatment thus misdiagnosing the patient entirely and not being aggressive enough with referral and treatment. As nurse practitioners we need to be very diligent and detail oriented in our assessment of patients. It is also critical we thoroughly assess all possible diagnoses and perform proper assessment techniques and ordering of tests.