The Doctors Company analyzed 649 claims against two types of advanced practice providers (APPs): physician assistants (PAs) and nurse practitioners (NPs).

The analysis revealed that the most common patient allegations in both PA and NP claims were related to diagnosis.

Case Example: PA

A 59-year-old female underwent redo quadruple coronary bypass grafting surgery. Her WBC was 13.9 prior to discharge.

When the patient was next seen, the sternal wound was healing well.

The patient's spouse subsequently testified that his wife complained of neck and shoulder pain during the visit. He called the physician's office two days later and spoke with a PA, who advised him to increase the patient's pain medication.

The spouse reported contacting the physician three days later and was again directed to the PA. He reported a continued complaint of pain.

The following day, the patient was experiencing chest pain with movement and deep breathing. She was instructed to report to the ER. An EKG was unremarkable. Her WBC was 14.8. The patient was discharged with a diagnosis of "chest wall pain."

The following day, the patient again phoned the physician. She was instructed to continue taking the pain medication. The patient sought care from a chiropractor, who noted a reddened, swollen area at the incision site.

That evening, the patient called the physician and was directed to a PA. She was given instructions to continue the pain medications. The patient's spouse testified that he called the physician five times the following day, demanding that the patient be seen. The physician admitted the patient, and she underwent surgery for a ventral epidural abscess. The patient was rendered an incomplete C6 quadriplegic.

Case Example: NP

A 41-year-old male presented with complaints of fever and abdominal pain with bright red clots from the rectum. The NP noted recent antibiotic therapy.

The NP suspected Clostridium difficile colitis. and prescribed Flagyl. The stool tested positive for Clostridium difficile toxin.

Four days later, the patient returned with complaints of bloody diarrhea and abdominal pain. The NP recommended continuing Flagyl and a repeat urinalysis.

One week later, the patient presented with bright red blood from the rectum and a moderate amount of abdominal pain. The NP recommended continued antibiotics.

One month later, the patient presented with complaints of persistent abdominal pain. The NP noted the abdomen was soft, and no further treatments or testing was ordered.

Two months later, the patient was seen for bloody diarrhea and abdominal pain. The NP ordered a stool culture. It is unknown whether testing for Clostridium difficile was repeated. The NP recommended that the patient avoid dairy products and take probiotics.

The patient continued to be seen over the next year with similar complaints.

One year later, due to persistent diarrhea, the patient was referred for a colonoscopy, which revealed a large sigmoid mass positive for Stage IIIA cancer.

Risk Mitigation Strategies

The following strategies can help avoid issues revealed by the claims analysis:

• Develop written guidelines and protocols that specify an APP's responsibilities.
• Delineate under what circumstances the physician must personally assess the patient.
• Review and evaluate APP medical record documentation.
• Track and document incoming telephone calls, including the provider's responses.
• Engage the patient as part of the team.

The guide, Advanced Practice Provider Liability: A Preventive Action and Loss Reduction Plan, includes additional strategies.

---

This article was written by Howard Marcus, MD, FACP, and Susan Shepard, MSN, RN, Senior Director, Patient Safety Staff Education.

Reprinted with permission. ^©2019 The Doctors Company (www.thedoctors.com). This article originally appeared in The Doctor's Advocate, third quarter 2019.

The guidelines suggested here 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.