Nurse Practitioner Case Study: Failure to properly monitor a patient on a medication that can cause organ failure

Defendant is a Nurse Practitioner working at a college infirmary.

Medical malpractice claims may be asserted against any healthcare provider, including nurse practitioners. This case study involves a nurse practitioner working at a college infirmary.

Presented by NSO and CNA
Legal Case Study with Risk Management Strategies
CASE STUDY Failure to secure an adequate history; failure to secure a thorough examination on a patient; failure to warn and advise a patient of risk involved in the use of medications; failure to properly monitor a patient on a medication that can cause organ failure 

Total Incurred: $850,000
(Monetary amounts represent only the indemnity settlement payment and/or legal expenses incurred on behalf of the treating nurse practitioner.)


An insured nurse practitioner, working at a college infirmary, was asked by a maintenance employee at the clinic for a terbinafine prescription for fungal toe infection. The nurse practitioner advised him to see his primary care provider for the prescription, but the employee explained that his primary care provider would not see him because of money owed. The insured reluctantly agreed to a one-time prescription but informed the employee that he would need to arrange with his regular practitioner for any further treatment. 

Later that day, the pharmacy contacted the nurse practitioner about changing the prescription from terbinafine ($400) to ketoconazole ($40). The insured agreed to the medication change but told the pharmacist that the employee would need bloodwork prior to beginning the prescription. The following day the nurse practitioner ordered baseline serum liver enzymes, which were normal. She then verbally instructed the employee to avoid alcohol and contact his primary care provider for monitoring and follow-up. 

A month later, the nurse practitioner left her employment at the college and had no further contact with the employee, who never followed up with his primary provider. He eventually suffered liver failure and needed an organ transplant due to acute hepatotoxicity. 

When the lawsuit was filed against the insured, she stated she never thought of the employee as a patient and had only prescribed him the medication as a favor.

Risk Management Comments

The insured nurse practitioner testified that she approved an one-time refill of the prescription, which the employee filled. No liver functions were performed before or after the refill and the only time the employee sought medical attention when was he was in liver failure. The employee was never able to work after his liver transplant and had three minor children living at home. 


After several attempts to resolve the matter for a compromised amount, several of the co-defendants would not agree to mediation. After six-years of defending the claim, it was eventually resolved with a mutual agreement with the employee and his family. 

Risk Management Recommendations
  • Discuss with the patient the need to be compliant of medical treatment and appropriate follow-up. Use language (spoken, written) the patient can understand.
  • Use caution when prescribing medications with known toxicity side effects, if a patient has difficulty being medically adherent.
  • Order and follow up with all indicated monitoring tests and document results in the patient healthcare information record. 
  • Consult with a pharmacist as needed, documenting all communication. 
  • Remain current regarding clinical practice, medications, biologics and equipment related to the diagnosis and treatment of illnesses and conditions encountered in one’s specialty.
  • Be cautious about treating or providing care to family, friends or co-workers. While it is not always easy to say no to requests from relatives and friends, the situation may cloud professional judgment and lead to ethical lapses. 
  • Politely decline any suggestions or recommendations from a patient that could jeopardize their safety or lead to later questions about one’s clinical expertise and/or judgment.
  • Refrain from personal relationship outside of the care setting with patients and their family members.

Guide to Sample Risk Management Plan

Risk Management is an integral part of a healthcare professional’s 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 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.

The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2018 CNA. 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.

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