Nurse Practitioners and Medical Malpractice

Presented by NSO and CNA

M
edical malpractice claims can be asserted against any healthcare provider, including nurse practitioners.
Although there may be a perception that physicians are held responsible for the majority of lawsuits, the reality
is that nurse practitioners are more frequently finding themselves defending the care they provide to patients.
According to CNA HealthPros and NSOs 2009 nurse practitioner claims study encompassing ten years of nurse
practitioner claim data, over $64.8 million was paid for medical malpractice claims on behalf of nurse practitioners.*
Settlement Payment: $105,000 Legal Expenses: $24,627
Note: There were multiple co-defendants in this claim who are
not discussed in this scenario. While there may have been
errors/negligent acts on the part of other defendants, the case,
comments, and recommendations are limited to the actions of
the defendant; the nurse practitioner.
The decedent/plaintiff was a 76-year-old female admitted to the
hospital for congestive heart failure. She was placed on a
respirator and sedated. ICU staff obtained telephone consent
from the plaintiff s daughter for placement of a peripherally
inserted central catheter (PICC). The defendant nurse
practitioner was a PICC specialist employed by an agency that
contracted with the hospital for placement of PICC lines for its
inpatients.
During the first PICC placement attempt, the defendant nurse
practitioner nicked the brachial artery. He applied pressure to
the resulting hematoma, and his second PICC insertion attempt
was successful. The defendant nurse practitioner documented
that the patient had a moderate hematoma and ordered the arm
elevated, the application of warm moist heat for 20 minutes, 4
times per day for 48 hours, dressing changes and to notify the
contracted PICC agency in the event of an increase in the
circumference of the patients arm.
Brachial artery bleeding continued unchecked, expanding the
hematoma and resulting in compartment syndrome. The
surgeon identified and repaired an actively bleeding tear in the
brachial artery and performed a fasciotomy. Following surgery,
the plaintiff developed signs of clinical deterioration and died
the following day. The autopsy revealed a 19-inch contusion of
the right arm and chest involving 400 ml of clotted blood,
congestive heart failure, atherosclerotic heart disease, chronic
obstructive pulmonary disease and liver fibrosis.
Expert review identified the following departures from the
standard of care regarding the defendant nurse practitioner:
Failure to apply pressure to the area of the arterial injury
until bleeding ceased
Failure to consider the effect of the plaintiffs medication
(Plavix) on the bloods ability to clot
Improper orders for warm moist compresses which could
increase bleeding
Failure to mark the baseline hematoma borders and record
the arm circumference
Absence of orders requiring close monitoring with frequent,
visual inspection of the hematoma borders, circumference
re-measurement, and palpation of the radial artery
Failure to contact the physician immediately, or at a
maximum, within one hour of the arterial injury
CASE STUDY WI TH RI SK MANAGEMENT STRATEGI ES
Case Study: Improper technique, improper assessment and treatment of
hematoma; failure to notify the physician and intensive care staff of the need
for close monitoring of hematoma and patient condition
Resolution
Experts determined that the nurse practitioner had breached the standard of care. The claim was settled for $105,000 with an
additional $24,627 in legal expenses. The total settlement amongst all of the defendants in the case was not available.
*Understanding Nurse Practitioner Liability: CNA HealthPro Nurse Practitioner Claims Analysis 1998-2008, Risk Management Strategies and Highlights of the 2009 NSO Survey, CNA Insurance
Company, December 2009. To read the complete study visit www.nso.com/NPclaimstudy2009
This publication is for educational purposes. It is not legal, professional or medical advice. CNA makes no representations as to its correctness or completeness and accepts no liability for any
injury or damage that may arise from its use. Specific legal or medical questions should be referred to a competent attorney or medical professional before applying this material in any particular
factual situations. This material may address and discuss matters for which your policy does not provide coverage, and the material does not create or imply the existence of coverage. Please
consult your insurance policy for the specific terms, coverages, amounts, conditions and exclusions of coverage. All products and services may not be available in all states and may be subject to
change without notice. CNA policies are underwritten by the property/casualty companies of CNA, Chicago, IL. CNA is a registered trademark of CNA Financial Corporation. 2012 Continental
Casualty Company. 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. This publication is published by Affinity Insurance Services, Inc., with headquarters at
159 East County Line Road, Hatboro, PA 19040-1218. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited.
Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc.; (AR 244489); in CA, MN & O , AIS Affinity Insurance Agency, Inc. (CA 0795465); in CA, Aon Affinity
Insurance Services, Inc., (0G94493), Aon Direct Insurance Administrator and Berkely Insurance Agency and in NY and NH, AIS Affinity Insurance Agency. 2012 Affinity Insurance Services, Inc.
X-8610-0112
Guide to Sample Risk Management Plan
Prior to PICC insertion, review the patients medications to identify those that would affect bleeding/clotting times
and consider that effect when determining the appropriate pressure application time at the site of the arterial puncture.
Timely notify the physician of an arterial injury occurring during insertion of a vascular access device.
Request prompt (not longer than one hour) physician consultation for any signs of continued bleeding following the
arterial puncture.
Remain with the patient until bleeding cessation is established or until the physician has assumed the care of the
patient.
Ensure the care team is aware of necessary ongoing treatment, observation, assessment and reporting of the status of
the site following arterial puncture.
Document the actions taken, pressure application time, determination of bleeding cessation, physician notification of
arterial injury with orders for continued observation, measurement and interventions, as needed.
Risk Management Recommendations
In addition to the failure to act within the standard of care, the lack of effective written documentation and verbal communication
between the defendant nurse practitioner and the ICU staff were significant factors in the unchecked expansion of the hematoma,
as well as the delay in obtaining physician assessment and intervention.
Risk Management Comments
Risk Management is an integral part of a healthcare professionals 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 www.nso.com/riskplan 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.