Nurse practitioners face malpractice risks similar to those of physicians. Hospitals should provide similar types and levels of education in risk management.

• Nurse practitioners will soon make up almost one-third of the family practice workshop.

• Diagnosis-related claims are most common, followed by medication-related claims.

• Physician supervision requirements can create liability risks.

When it comes to medical malpractice risks and the strategies for minimizing liability, risk managers should look at nurse practitioners (NPs) almost the same as physicians, according to a recent analysis of claims data.

However, requirements for physician supervision are one area that requires additional attention.

A review of closed claims by The Doctors Company, a malpractice insurance provider in Napa, CA, found that while top NP risk areas are fairly equivalent to those of physicians and can be addressed by similar strategies, many NP risk factors can be remedied if physicians are clear about NP laws and regulations within their state and support the NP in providing care within the scope of practice.

NPs are projected to make up almost one-third of the family practice workforce by 2025, notes David B. Troxel, MD, medical director of The Doctors Company. NPs have become increasingly popular in recent years because they allow a physician practice or hospital clinic to see a higher volume of patients while also allowing doctors to focus on more complex care.

“This is a key area for risk management because a lot of doctors are so focused on using nurse practitioners as extenders that they don’t always follow as closely as they should the scope of practice requirements and limitations,” Troxel says. “Each state has its own regulations defining what they can and cannot do, so it becomes very important for physicians and risk managers to understand what the role of the nurse practitioner can be in your own state.”

Troxel notes that though claims frequency has been gradually declining for physicians in recent years, it has been rising for NPs. That may simply be a result of the increasing use of NPs over the past decade, and the NP claims frequency is still low, he says.

“They still get sued less often than physicians, and when they get sued the payout involving a nurse practitioner is statistically much lower than that for a physician,” Troxel says. “The risk for having a nurse practitioner is really quite low, and the steps to take for making that risk even lower are quite simple.”

Similar Risk Management Approach

The Doctors Company studied malpractice claims involving NPs over a six-year period, comparing them to claims against primary care physicians. The analysis excluded claims in which the patient was seen by both an NP and the supervising physician. The most common claim allegations were similar for both groups, suggesting that risk management strategies also should be similar, Troxel says.

Physicians had more claims for medical management allegations, which Troxel says is not surprising because they treat more complex patients than NPs.

Diagnosis-related claims and medication-related claims were the most common in both groups, but many nurse practitioner malpractice claims can be traced to clinical and administrative factors, the study found. Those factors include a failure to adhere to nurse practitioner scope of practice.

Other factors specific to NPs include an absence of or deviation from written protocols, and inadequate physician supervision.

“Many of these factors can be remedied if physicians are clear about the nurse practitioner laws and regulations within their state and support the nurse practitioner in providing care within the scope of practice,” the report authors wrote. “There should be agreement on the level of supervision that will be exercised by the physician, including the number and frequency of charts to be reviewed and co-signed. Additionally, nurse practitioners and supervising physicians should agree on specific conditions that, when identified by a nurse practitioner, warrant assessment by the supervising physician.” (The study is available online at: https://bit.ly/2EAN2ko.)

The research indicated that claims involving NPs were generated by failures by both the NP and the supervising physician, Troxel notes. Inadequate physician supervision was at the root of many NP claims, but another prominent factor was the NP’s delay in obtaining a consult from the supervising physician or a specialist, or failing to make a referral to another doctor.

“This all gets down to how a physician practice is managed and how aware they are of what a nurse practitioner can and cannot do,” Troxel says. “It is relatively easy to understand your state requirements and communicate that to NPs in your practice, but somebody has to actually do it. The problem is that many physicians, especially in small practices where they don’t have much administrative staff, don’t have the time to take a few hours out when they hire someone and go over all these things. Over time they get comfortable with a nurse practitioner, grow confident in how they perform, and they drift away over time, letting them operate more and more independently.”

That is why it is important for the physician and NP to agree on specific conditions or situations that require the physician’s input, Troxel says. That may be as specific as a list of potential diagnoses for which the physician must always see the patient, he says, and a good working relationship will have the NP feeling comfortable enough to always ask the doctor for advice rather than feeling reluctant to impose on his or her time.

By the same token, the physician must be open to such consults and not discourage the NP from asking for input when necessary, Troxel says. Physicians look to NPs to improve their efficiency and better manage the patient load, but substantial liability risk is created if the doctor gives the impression that the NP should not waste his or her time with patient consults, he says. Better to err on the side of caution and encourage the NP to speak up when in doubt.

“NPs tend to be very much liked by patients and having them in the practice can be an excellent experience for the physician,” Troxel says. “The key is being aware of the scope of practice and having a structure in place to help the nurse practitioners work to the best of their abilities while still including the doctor when appropriate.”


• David B. Troxel, MD, Medical Director, The Doctors Company, Napa, CA. Email: dtroxel@thedoctors.com.