M edical malpractice claims can be asserted against any healthcare provider, including nurse practitioners. Although there may be a perception that physicians are held responsible for the majority of lawsuits, the reality is that nurse practitioners are more frequently finding themselves defending the care they provide to patients. According to CNA HealthPros and NSOs 2009 nurse practitioner claims study encompassing ten years of nurse practitioner claim data, over $64.8 million was paid for medical malpractice claims on behalf of nurse practitioners.* This case study involves a nurse practitioner working in a medical clinical environment. Settlement Payment: $77,500 Legal Expenses: $166,696 continued... Note: There were multiple co-defendants in this claim who are not discussed in this scenario. Monetary amounts represent only the payments made on behalf of the nurse practitioner. Any amounts paid on behalf of the co-defendants are not available. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the nurse practitioner. The patient / plaintiff was a 45-year old woman with cardiac disease including mitral valve replacement, aortic valve replacements (three), prior cerebral vascular accident (CVA) and atrial fibrillation, who was receiving anticoagulant therapy with Coumadin and who was experiencing persistent and increasing pelvic pain. The patients gynecologist diagnosed enlarging uterine myoma and referred the patient for an endometrial biopsy. The treatment plan anticipated that if the biopsy were benign the patient would then undergo bilateral uterine artery embolization (UAE). The gynecologist ordered medical cardiac clearance in preparation for the proposed UAE. The defendant nurse practitioner examined the patient and apparently did not correctly understand the nature of the procedure for which clearance had been requested. The defendant nurse practitioner also provided medical and cardiac clearance that she believed was clearance only for the biopsy procedure. The defendant nurse practitioner provided the patient with only a handwritten note instructing her to cease the Coumadin medication four days prior to her procedure and also instructing her to speak to her surgeon regarding her Coumadin. The physician performing the biopsy subsequently instructed the patient to continue her Coumadin before and after the biopsy. The biopsy was negative and the patient was scheduled for the UAE procedure. The patient claimed to have been confused about her Coumadin prior to the UAE. Based upon the handwritten note provided by the defendant nurse practitioner, the patient ceased her Coumadin four days prior to the UAE surgery. It was disputed whether the patient informed her physician that she had stopped her Coumadin, but her surgeon did not order any replacement for the Coumadin prior to the UAE procedure. The patient was instructed to resume her Coumadin upon discharge. Shortly after discharge, and before the patient could resume her Coumadin, she suffered an embolic stroke and cerebral infarct. Her symptoms were significant, including left sided weakness, gait disturbance, loss of range of motion of her left arm and hand, memory loss, confusion, mental anguish and emotional distress. CASE STUDY WI TH RI SK MANAGEMENT STRATEGI ES Case Study: Alleged Failure to Obtain Proper Medical History; Improper Medical Clearance; Improper Management of Anticoagulant Medication; Failure to Communicate with the Referring Surgeon; Failure to Properly Document Clinical Findings; Failure to Provide Proper Patient Instructions for Preoperative Management of Coumadin Therapy; and Failure to Order an Appropriate Coumadin Substitute *Understanding Nurse Practitioner Liability: CNA HealthPro Nurse Practitioner Claims Analysis 1998-2008, Risk Management Strategies and Highlights of the 2009 NSO Survey, CNA Insurance Company, December 2009. To read the complete study visit www.nso.com/NPclaimstudy2009 This publication is for educational purposes. It is not legal, professional or medical advice. CNA makes no representations as to its correctness or completeness and accepts no liability for any injury or damage that may arise from its use. Specific legal or medical questions should be referred to a competent attorney or medical professional before applying this material in any particular factual situations. This material may address and discuss matters for which your policy does not provide coverage, and the material does not create or imply the existence of coverage. Please consult your insurance policy for the specific terms, coverages, amounts, conditions and exclusions of coverage. All products and services may not be available in all states and may be subject to change without notice. CNA policies are underwritten by the property/casualty companies of CNA, Chicago, IL. CNA is a registered trademark of CNA Financial Corporation. 2012 Continental Casualty Company. All rights reserved. This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. This publication is published by Affinity Insurance Services, Inc., with headquarters at 159 East County Line Road, Hatboro, PA 19040-1218. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited. Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc.; (AR 244489); in CA, MN & O , AIS Affinity Insurance Agency, Inc. (CA 0795465); in CA, Aon Affinity Insurance Services, Inc., (0G94493), Aon Direct Insurance Administrator and Berkely Insurance Agency and in NY and NH, AIS Affinity Insurance Agency. 2012 Affinity Insurance Services, Inc. x-8610-0812 Guide to Sample Risk Management Plan Obtain a full history and ensure a thorough understanding of the surgical plan of care prior to providing medical clearance. If there is any question or if more than one procedure is planned, clarify the scope of the clearance with the requesting surgeon prior to proceeding. Provide clear, concise patient instructions. Patient instructions should be written and discussed with the patient such that the patient can successfully repeat them back. Communicate the management of high risk medications such as anticoagulants among all members of the patients care team and document the agreed upon plan to ensure coordinated and continuous care. Provide written findings, recommendations and patient instructions to the referring physician. Document all findings, recommendations and patient instructions in the patients clinical record, including a copy of any written patient instructions and a copy of the document provided to the referring physician. Risk Management Recommendations Optimally, the defendant nurse practitioner would have discussed the surgical plan and coordinated the management of the anticoagulant therapy (including appropriate substitutes when Coumadin therapy was suspended) with the surgeon, ensured that all parties understood the plan and documented the plan for the surgeon, the patient and in the patients clinical record. Risk Management Comments Risk Management is an integral part of a healthcare professionals standard business practice. Risk management activities include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or eliminating these risks A good Risk Management Plan will help you perform these steps quickly and easily! Visit www.nso.com/riskplan to access the Risk Management plan created by NSO and CNA. We encourage you to use this as a guide to develop your own risk management plan to meet the specific needs of your healthcare practice. Resolution Multiple expert opinions were sought. All were critical of one or more of the following elements of the defendant nurse practitioners care: Failure to obtain the patients entire medical and cardiac history Failure to identify that the biopsy did not require medical clearance Failure to communicate with the referring physician to clarify the plan of care and the reason for the medical clearance Improper management of the patients anticoagulant therapy Improper, informal patient instructions Inadequate and inappropriate documentation When defense experts agreed that the defendant nurse practitioner had deviated from the standard of care in several areas, the decision was made to settle the claim on behalf of the nurse practitioner.