Nurse Practitioner Case Study: Failure to follow-up on lab results

This case study involves a nurse practitioner in private practice setting.

Our insured practitioner in this case was a family nurse practitioner (NP) who owned her own family medicine practice. The patient, a regular patient of the insured, had been to the emergency department (ED) on the prior day with a fever and cough. 

Upon discharge, the patient was instructed to follow up with his primary medical provider the following day. The patient told the NP that he had been diagnosed with an upper respiratory infection and prescribed Levaquin.  Laboratory work was ordered, but the results were not available when the patient was ready for discharge. 

On assessment, the patient stated he felt a little better but still had a bad cough. The NP stated that she would get the laboratory results from the ED and that she wanted to see the patient back in the office in a few days. 
The ED sent the laboratory results to the patient’s cardiologist for review as the patient had an artificial aortic valve.  The cardiologist, in turn, faxed the results to the nurse practitioner two days later. 

The NP saw the patient again at the follow-up appointment. His chief complaint was that he continued to suffer with a cough but reported feeling better and had not had a fever in the past 24 hours. It was at this appointment that the NP had the laboratory results, which showed that the patient had bacteria in his blood. As the laboratory work was sent to the cardiologist first, the insured assumed the cardiologist had reviewed the results and taken whatever action was appropriate, so she did nothing further with them. 

Two days after seeing the insured, the patient developed endocarditis and had a cardiovascular accident (CVA).
 

Lawsuit alleging failure to follow up regarding infection

The claim was brought against the nurse practitioner, the cardiologist, the medical center and the ED physician. The plaintiff’s expert opined:
  • The ED physician failed to prescribe an appropriate antibiotic to treat the patient, and failed to follow-up with the patient when the blood cultures came back as positive for bacteria.
  • The cardiologist failed to follow-up with the ED physician, the patient and/or the nurse practitioner to ascertain about the patient’s treatment plan.
  • The insured NP failed to repeat the blood cultures, follow-up with the ED physician and/or cardiologist, and failed to send the patient to the hospital for intravenous antibiotics.  

The theme of the plaintiff’s malpractice argument was that the departures from the standard of care were the direct cause of the plaintiff’s undiagnosed endocarditis, resulting in the CVA. It appeared that the ED physician was the main target of the lawsuit and his failure to contact the patient after he received and reviewed the blood culture results. The ED physician settled his claim prior to trial, leaving our insured, the medical center, and the cardiologist in the case. 

Our defense experts opined:
  • The plaintiff’s CVA was caused by atrial fibrillation not an infection; and
  • The patient had fully recovered to his baseline condition (the patient testified he was feeling good and did not have any current problem).

Discussions on whether to proceed at trial included:
  • Positive expert reviews of the NP’s actions;
  • Weak causation arguments; and
  • Good prognosis by defense counsel regrading trial outcome.
In medical malpractice cases, the burden lies with the plaintiff to prove four elements exist for an incident to be considered malpractice: 1) duty, established by a provider-patient relationship, 2) a breach of the standard of care, 3) the plaintiff’s injury was caused by the provider’s error or omission, and 4) the plaintiff’s injury resulted in damages. The defense experts in this case had generally positive expert reviews of the NP’s actions and they felt that the plaintiff had a weak causation argument so, the decision was made to vigorously defend our insured NP in court. 
 

After the trial

The jury trial lasted five days. Deliberation lasted approximately 20 minutes, and the jury returned with a defense verdict. 

The jury found that the medical center had not breached the standard of care. Furthermore, the jury found that while the insured NP deviated from the standard of care, the deviation was not a proximate cause of the patient’s injuries. 

The total incurred in this case was greater than $137,000 in legal expenses, representing a successful defense of our insured NP. 
 

Risk Control Recommendations for treating Nurse Practitioners 

  • Provide leadership in the coordination of inter-professional healthcare for integrated delivery of healthcare patient services to achieve safe effective, efficient, timely, patient-centered, and equitable care. (IOM, 2010) 
  • Maintain competencies (including experience, training, and skills) consistent with the needs of assigned patients and/or patient care units.
  • Engage in timely and proactive discussions with physicians and other members of the care team to ensure that the team is educated about the patient’s treatment plan.
  • Thoroughly report in a timely manner any changes in the patient’s condition and/or response to treatment and document such interactions, as well as any revisions in the treatment plan in the patient’s clinical record.
  • Document pertinent anesthesia-related information on the patient healthcare record in an accurate, complete, legible, and timely manner.
  • Communicate in a timely and accurate manner both initial and ongoing findings regarding the patient’s status and response to treatment.
  • Report any patient incident, injury or adverse outcome and subsequent treatment/response to risk management or the legal department.

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