What We Learn From Advanced Practice Provider Malpractice Claims

June 22, 2023
Failure to diagnose subdural hemorrhage leads to death

A 72-year-old woman was rolling her garbage can out to the curb when she fell on to the concrete driveway. She hit her head, injured her left hand and left side of her chest. She called her daughter, who suggested she seek medical care, but the woman refused. Five days later, she presented with her daughter to her primary care physician (PCP) with complaints of lacerations on the left hand, pain, cough with trouble breathing, and multiple abrasions on her face.

A nurse practitioner (NP) examined the woman and noted she was at risk for complications related to her history of osteoporosis and anticoagulation medication. The NP prescribed an oral antibiotic and an antibiotic ointment for the lacerations on the woman’s face and hand. She also instructed the woman to see her regular PCP in one week or sooner if problems developed.

The next afternoon, the woman was discovered dead at home by her grandson, who had come over to check on her when she didn’t answer her daughter’s phone calls. Her grandson contacted EMS, who declared her dead upon their arrival. The medical examiner performed an autopsy, which revealed the cause of death to be a subdural hemorrhage.

Her family filed a malpractice claim against the NP, the supervising PCP and the clinic, alleging failure to diagnose a subdural hemorrhage resulting in death. The experts who reviewed the care were critical of the NP for failing to perform a thorough neurologic exam, not testing the woman’s INR level and for failing to rule out internal bleeding in a patient taking anticoagulants with significant facial and head injuries. The case was settled with a payment made to the family on behalf of the NP, the supervising PCP and the clinic who employed the NP.

Top allegations in advanced practice provider (APP) claims

In an analysis of our malpractice claims involving advanced practice providers (NPs and PAs), diagnostic error is the costliest and most frequent allegation. When we analyzed the cases involving APPs, we found that the allegations made against these providers were the same as the allegations made against physicians in the same specialty practice areas.

APPs who work in family medicine and emergency medicine are vulnerable to diagnostic error allegations. Those APPs working in surgical practices face allegations of improper performance and improper surgical patient management. Obstetrical-focused APP risks include delay in recognition and treatment of fetal distress and improper postpartum patient management.


Both charts reflect Constellation claims reviewed 12/31/2022

Our review of APP cases revealed team-related vulnerabilities, including:
• Clinical judgment factors due to insufficient mentoring and collaboration opportunities with physicians.
• Communication breakdowns among the care team due to absence of teamwork training and skills.
• Administrative issues, typically inadequate physician oversight, due to role clarity and a lack of an APP policy.

APP employment is increasing

According to the Association of American Medical Colleges (AMCC), the U.S. faces a projected physician shortage of up to 124,000 physicians by 2034, with demand for physicians outpacing supply. The employment of APPs (NPs and PAs) to fill these roles is increasing. The U.S. Bureau of Labor Statistics predicts a 40% growth for NP roles and a 28% growth for PA roles between 2021 and 2031.

Strategies to enhance APP roles and mitigate their risks

With the increasing employment of APPs, the strategies to enhance their roles and mitigate their risks include:

  1. Utilizing a team-based care model and implementing APP feedback with regular physician collaboration opportunities.
  2. Enhancing teamwork and communication skills by providing training and tools, such as SBAR and I-PASS.
  3. Implementing a formal APP policy outlining roles and responsibilities, scope of practice, state supervision requirements, prescribing authority, physician oversight and physician consultation triggers.
  4. Providing clinical decision support tools to help APPs develop robust differential diagnosis lists and assist in the management of surgical patients.
  5. Investing in joint team training (physicians, APPs and nurses) on fetal heart rate (FHR) and uterine contraction monitoring using improved communication, NICHD (National Institute of Child Health and Human Development) language and standardized FHR pattern recognition and management.  
Risk reports

Our risk reports analyze malpractice claim data on a variety of topics and specialties, including for APPs, family medicine, surgical specialties and obstetrics. Each risk report shares insights to help reduce harm events and malpractice claims.

Are you a Constellation client? Sign in to MyAccount to access exclusive customer versions of our risk reports. The expanded reports share actionable insights and strategies you can utilize to help reduce harm events and malpractice claims. After you sign in to MyAccount, follow Risk Resources > Tools & Resources > Publications > Risk Reports. You also have access to a host of Bundled Solutions (in Risk Resources) that cover a wide variety of topics to assist you in your risk mitigation efforts.

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