Nurse Practitioner Case Study: Failure to diagnosis blood clot resulting in irreversible ischemia, below the knee amputation

Patient non-adherence can come in many forms: inability or unwillingness to follow a course of therapy, repeated missed appointments, rejecting treatment recommendations, reluctance to take medications, refusal to provide information, or chronic late payments. If left unaddressed, such conduct may result in adverse patient outcomes and even litigation. This medical malpractice case study and risk management strategies, presented by NSO and CNA, involves a family nurse practitioner (FNP) who worked in a nurse practitioner office setting.



A 46-year-old male established care with the insured family nurse practitioner (FNP). The patient had recently broken his wrist and, while in the emergency department (ED), he was informed that “his blood sugar was really high and he needed to find a primary care provider to get it under control”. A finger stick Hemoglobin A1C was performed, reflecting a level of 11.5 percent. The patient did not have health insurance, so the FNP decided to start him on insulin as the medication and supplies would be available at no charge. The following was documented in the patient’s healthcare information record:

  • Monitor blood sugar levels and keep a blood sugar log.
  • Prevention and treatment for hypoglycemia.
  • Education on how to administer the insulin, carbohydrate dietary measures and the importance exercise.
  • Follow up with ophthalmology on a comprehensive eye examination.
  • Perform daily examinations of his feet and ensure proper foot care and wear.
Over the next three to four months, despite missing a few appointments and failing to adhere to his insulin regimen, the patient’s blood sugar levels were in better control.
Nine months after his initial appointment with the insured FNP, the patient presented with complaints of pain to the top and side of the left foot. The patient reported he was uncertain if he had twisted it, went to an urgent care facility and had an x-ray, which was reportedly negative for any fractures.
A small bruise was documented to the top of the foot. He reported that he may have done something to it over the weekend while at a jump park with his children. In addition, he reported that he broke a toenail and may have cut it too short. He was having a difficult time walking with any type of shoe. The patient’s non-fasting blood sugar was 194, pulse was 128 bpm, and his other vital signs were unremarkable.
The FNP documented the following: “The patient’s toenail (big toe) is cut short with skin exposed, red and purplish in color at the lateral border. The left foot revealed no swelling or deformity with intact range of motion though movement was painful. Tenderness is noted over the tarsal tunnel.”
The FNP ordered lab work (CBC, CMP, and CPK level) and left lower extremity arterial Doppler color flow studies for a “left foot painful.” His was given an antibiotic and instructed to use non-steroidal anti-inflammatory drugs (NSAIDs) for musculoskeletal pain. An ace wrap was applied to the ankle and he was told to apply ice to his ankle to reduce the swelling. The patient declined all testing due to costs. The FNP instructed the patient that, if he did not want the testing,  he should go to the ED as she thought he could have a blood clot. The patient reported that he would only go to the ED if his condition worsened.
Three days later, the patient was evaluated in the ED with a complaint of pain to the left thigh and foot, as well as a cold sensation in his foot. He reported that he had seen his primary care provider and had been placed on antibiotics, but the pain was getting worse. Physical evaluation revealed a completely cold left foot without dorsalis pedis pulse. His serum Creatine Kinase was 1608 IU/L and white blood cell count was 16.7 K/uL. A CT angiogram revealed an occlusion of the anterior tibial artery, posterior tibial and peroneal arteries and reconstituted peroneal artery identified at the level of the ankle joint. He was admitted for a possible thrombophilic disorder or idiopathic thrombophilic disorder and surgical intervention. The patient ultimately underwent a left below the knee amputation due to irreversible ischemia to the left lower extremity.
The patient filed a malpractice claim against the FNP, the FNP’s employer, the medical center and the surgeon who performed the initial surgical intervention.

Risk Management Comments

The patient’s allegations against the FNP included:
  • Failure to perform an adequate diabetic food exam;
  • Failure to document the temperature on the left foot;
  • Negligently diagnosing cellulitis/abscess and
  • Negligently ordering compression and ice for a cold foot.
Defense experts were supportive of the FNP’s care and testified that her documentation of the patient’s care was thorough. Defense counsel believed that the case was defensible, but the other defendants in the case were engaging in finger pointing, making the defense of the FNP more difficult.


The FNP was ultimately dismissed from the case on summary judgment. The claim lasted seven years and expense costs to defend the insured FNP exceeded $140,000.
Total Incurred: Over $140,000
(Note: Figures represent only the defense expense payments made on behalf of our nurse practitioner and do not include any payments that may have been made by the NP’s employer on her behalf or payments from any co-defendants. Amounts paid on behalf of the multiple co-defendants named in the case are not available.)

Risk Control Recommendations

  • Compile a comprehensive patient clinical history, as well as relevant social and family history.
  • Document all patient-related discussions, consultations, clinical information and actions taken, including any treatment orders that are provided.
  • Perform a physical examination to determine the patient’s health status and evaluate the patient’s current symptoms/complaints.
  • Record all patient non-adherence with ordered testing and treatment, as well as all counseling given, and other efforts made to encourage compliance.
  • If non-adherence is related to a lack of health insurance or financial resources, refer the patient to appropriate resources, such as social agencies and/or free or low-cost clinics, and follow up to ensure compliance.
  • If the 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.
  • Discuss clinical findings, diagnostic test/procedure results, consultant findings, diagnosis, the proposed treatment plan, and reasonable expectations for the desired outcome with patients, in order to ensure their understanding of their care or treatment responsibilities. Document this process, noting the patient’s response.
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.

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