Diagnosis-related allegations represent a significant area of liability for nurse practitioners (NPs). Diagnosis-related allegations can stem from factors such as the NP’s failure to order appropriate diagnostic tests to establish a diagnosis, failure to obtain a complete patient and family history and thorough patient physical assessment, and/or a lack of sound documentation supporting the decision-making process of the treating NP. This case study involves a nurse practitioner (NP) who was working in an urgent care clinic.
This case study involves an NP working in an urgent care clinic in a rural, wooded area of the South. In the summer, a 3-year-old male patient presented to the clinic with fever, nausea, and rashes on his wrists and ankles. At this initial visit, the patient was evaluated by another provider working at the urgent care clinic. The other healthcare provider prescribed Amoxicillin and advised the patient’s parent to return to the clinic if there was no improvement. The patient’s fever and rash continued to worsen over the next day, so the patient’s parent brought him back for reassessment.
The NP assessed the patient and diagnosed him with hand, foot, and mouth disease due to the rashes on the patient’s wrists and ankles. At the time of this visit, the rashes had spread to his palms and the soles of his feet. The NP also concluded that the patient appeared to be having an adverse reaction to the Amoxicillin. The NP advised the patient’s parent to stop administering the Amoxicillin and informed the parent that the virus would clear up on its own in a few days.
The patient’s condition deteriorated over the next several days, eventually requiring hospitalization and treatment for seizure activity, cardiac dysfunction, and respiratory compromise which required intubation. During the patient’s hospitalization, laboratory testing revealed that the patient was suffering from Rocky Mountain spotted fever (RMSF). The patient was treated with antibiotics and was able to be discharged from the hospital after 10 days.
Two years after the patient was discharged, the patient’s parents filed a lawsuit against the NP, the other healthcare provider who initially evaluated and treated the patient, and the urgent care clinic. By the time the lawsuit was initiated, the NP no longer worked for the urgent care clinic, and the clinic’s professional liability insurance coverage no longer extended to the NP. However, the NP had individual coverage through NSO.
Risk Management Comments
The NP failed to review documentation from the patient’s visit to the urgent care clinic two days earlier, which would have revealed that the patient had recently sustained a tick bite. Defense experts opined that the NP should have been aware of the risk of RMSF, especially in young children, due to the following:
- The NP practiced in one of the five states responsible for >60% of cases of RMSF.
- The patient presented during the summer months, when tick bites are more common, and transmission of RMSF is high.
The NP also failed to document a comprehensive history and physical of the patient, as well as her rationale for concluding that the patient was having an allergic reaction to the Amoxicillin.
Due to the low likelihood of a defense verdict if the case proceeded to trial, the NP agreed to the defense recommendation to offer to settle the case.
Two and a half years after the lawsuit was filed, the parties agreed to a settlement. The claim resolved with a total incurred of greater than $160,000.
After the lawsuit was settled, the settlement payment was reported to the State Board of Nursing (SBON), as required by law. The SBON investigated the NP’s conduct, and ultimately ordered the NP to complete 20 hours of continuing education courses and pay a $500 fine. The total costs incurred to defend the NP in the SBON matter exceeded $6,300.
(Note: Figures represent only the payments made on behalf of the insured nurse practitioner and do not include any payments that may have been made from any co-defendants. Amounts paid on behalf of the co-defendants named in the case are not available.)
Risk Control Recommendations
- Compile, document and utilize an appropriate comprehensive patient clinical history, as well as relevant social and family history.
- Perform a physical examination to determine the patient’s health status and evaluate the patient’s current symptoms/complaints.
- Document all patient-related discussions, consultations, clinical information and actions taken, including any treatment orders or education that are provided.
- Consider the findings of the patient’s assessment, history, and physical examination, as well as the patient’s expressed concerns, in establishing a diagnosis, and document findings.
- Utilize evidence-based clinical practice guidelines or protocols when establishing a diagnosis and providing treatment and document the clinical rationale for any deviation from protocols.
- Seek timely specialist consultations and advice regarding patients with recurring complaints and/or signs and symptoms that do not respond to prescribed treatment.
- If a patient is uninsured or unable to afford necessary diagnostic and consultative procedures, refer the patient for financial assistance, payment counseling, and/or free or low-cost alternatives, and document these actions.
- Remind patients to seek emergency treatment if a condition worsens and document this action.
- If a patient is unstable, acutely ill, and in need of immediate diagnostic testing and/or consultation, refer the patient to hospital emergency care to facilitate this process.
Centers for Disease Control and Prevention (CDC). (2019). Rocky Mountain Spotted Fever (RMSF) – Information for Healthcare Providers. Retrieved August 2, 2022, from https://www.cdc.gov/rmsf/healthcare-providers/index.html
Stanford Medicine Children’s Health. (n.d.). Rocky Mountain Spotted Fever (RMSF) in Children. Retrieved August 2, 2022, from https://www.stanfordchildrens.org/en/topic/default?id=rocky-mountain-spotted-fever-rmsf-in-children-90-P02538
Disclaimer:These are illustrations of actual claims that were managed by the CNA insurance companies. However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. This material is for illustrative purposes and is not intended to constitute a contract. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, NSO websites are provided solely for convenience, and Aon, AIS, NSO and NSO disclaims any responsibility with respect to such websites. This information 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.
Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.