Download Understanding Nurse Practitioner Liability

 urse practitioners
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are at the forefront
of a paradigm shift
occurring in today’s
healthcare industry.
Understanding Nurse Practitioner Liability:
CNA HealthPro Nurse Practitioner Claims Analysis 1998-2008,
Risk Management Strategies and Highlights of the 2009 NSO Survey
Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CNA HealthPro Nurse Practitioner Claims Analysis 1998-2008 . . . . . . . . . . . 5
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Legal and Regulatory Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Claims Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Database and Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Ultimate Severity of Claims by Accident Year. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Analysis of Claims by Claim Category. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Analysis of Claims by Clinical Specialty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Analysis of Claims by Location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Analysis of Claims by Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Analysis of Claims by Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Analysis of Claims by Allegation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Analysis of Allegations Related to Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Analysis of Allegations Related to Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Analysis of Allegations Related to Medication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Analysis of Injuries Resulting in Death. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Analysis of Closed Claims with the Highest Indemnity Payments . . . . . . . . . . . . . . . . 22
Risk Management Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Scope of Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Health Information Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Diagnosis and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Medication Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Highlights from the NSO 2009 Nurse Practitioner Survey. . . . . . . . . . . . . 29
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Survey Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
NSO Survey Excerpts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Demographics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Nurse Practitioner Education/Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Clinical Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Clinical Hours Required in Nurse Practitioner Programs. . . . . . . . . . . . . . . . . . . . . . . . 35
Years as a Registered Nurse Prior to Becoming a Nurse Practitioner . . . . . . . . . . . . . 36
State Regulations Governing Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Years of Experience as a Nurse Practitioner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Significance of a Mentor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Practicing Outside of Certification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Years Working in Specified Position at Time of Incident. . . . . . . . . . . . . . . . . . . . . . . . 42
Prescriptive Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Daily Patient Workload. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Overtime. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4
Introduction
CNA HealthPro and the Nurses Service Organization (NSO) currently insure
approximately 25,000 nurse practitioners nationwide. As major providers of
professional liability insurance for nurse practitioners, CNA HealthPro and
NSO are dedicated to assisting our clients in mitigating risk. We express our
commitment through collaboration, consultation and educational efforts
aimed at raising client awareness of medical malpractice issues.
Five years ago, CNA HealthPro collaborated with NSO to publish the Nurse
Practitioner Claims Study 1994–2004. This update analyzes reported events
from CNA-insured nurse practitioners that occurred between 1998 and 2008.
It examines the litigation environment, analyzes professional liability risks
associated with nurse practitioners and offers current risk management recommendations related to key findings.
To enhance the discussion, NSO surveyed nurse practitioners insured through
the NSO program regarding the relationship between liability and a variety
of professional factors, such as level of supervision and prescribing authority.
Highlights of the NSO survey results are provided, beginning on page 29.
The full NSO survey can be accessed at www.nso.com/NPclaimstudy2009.
Please note that the CNA HealthPro claims review and the NSO survey
exclude claims associated with registered nurses, certified registered nurse
anesthetists and certified nurse midwives. Nurse practitioner, as defined
here, includes clinical nurse specialists, except where clinical nurse specialists
are cited separately.
5
CNA HealthPro
Nurse Practitioner Claims Analysis 1998-2008
Executive Summary
This publication presents CNA HealthPro nurse practitioner claims data for
events that occurred between January 1, 1998 and December 31, 2008. The
following study findings are of special import for nurse practitioners:
-Ultimate average indemnity and expense payments have increased
over the past 10 years. (Figures 1a and 1b)
-Adult/geriatric, family and pediatric/neonatal medicine specialties
continue to have the most claims. (Figure 3a)
-The pediatric/neonatal specialty has the highest average severity.
(Figure 3b)
-The medical care office is the location with the highest number
of claims. (Figure 4a)
-Wrongful death is the most frequently alleged injury. (Figure 5a)
-Fetal/infant birth-related brain injury has the highest average
severity; however, this average is based on a small number of
closed claims. (Figure 5b)
-Diagnosis-related allegations account for 39 percent of open and
closed claims. (Figure 7a)
-Scope of practice-related allegations are relatively rare, but they
have the highest average severity. (Figure 7b)
-Failure to order/obtain appropriate consultation/referral has the
highest severity among treatment-related allegations. (Figure 9b)
-More than 80 percent of medication errors are prescription-related.
(Figure 10a)
-The injury that most frequently results in death is infection/
abscess/sepsis. (Figure 11a)
-Although relatively rare, complication from surgery, treatment,
procedure or medication has the highest severity among the
injuries that resulted in death. (Figure 11b)
-Cardiac condition is associated with 22.1 percent of the closed
claims that resulted in death and incurred an indemnity payment.
The average paid indemnity for these closed claims was $250,756.
(Figure 11b)
-Four closed claims that settled at the policy limit (i.e., $1 million)
resulted from allegations of failure to diagnose or failure to properly
assess. (Figure 12b)
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6
Legal and Regulatory Environment
Nurse practitioners are at the forefront of a paradigm shift occurring in today’s
healthcare industry. Ten years ago, nurse practitioners did not assume a
prominent role in patient care. However, as policymakers address the goal
of making healthcare accessible in all of our communities, they increasingly
focus upon the nurse practitioner. Today, physician groups, hospitals, aging
services organizations and other healthcare providers call upon the services
of nurse practitioners to maximize quality while maintaining affordability in
patient care.
As nurse practitioners assume a larger role in the healthcare industry, related
legal and regulatory issues also intensify. As a result, nurse practitioners now
occupy a central role in malpractice litigation. A threshold issue in such litigation often is the express regulatory authority of a nurse practitioner to render
certain types of patient care. With respect to scope of practice, however,
states differ dramatically in the professional activities that nurse practitioners
may perform. Some state statutory schemes expressly designate those practices in which a nurse practitioner may engage. Others define the scope of
practice through regulatory boards, which also may serve as disciplinary bodies authorized to investigate alleged transgressions. A few states delegate, to
varying degrees, the task of defining the scope of nurse practitioner practice
to the discretion of the supervising physician.
The roles and responsibilities of nurse practitioners are further defined by
policies, procedures and/or protocols promulgated by their employers. Many
policies or standing orders may operate to define the discretionary authority,
activities and scope of a nurse practitioner’s practice pursuant to statutory
and/or regulatory grants of authority. At the present time, delineating the
appropriate scope of practice may present more challenging issues for nurse
practitioners than for other healthcare professionals. Moreover, the desire to
free nurse practitioners to work more independently may create tension with
the need to comply with this complex and evolving framework of regulations
and practice rules. Therefore, administrators, nurse practitioners, other healthcare professionals and legal counsel must remain abreast of state-specific
scope of practice guidelines.
From a claims perspective, nurse practitioner liability issues are not always
limited to single defendants. Physicians, healthcare practice groups and other
healthcare organizations often become involved directly as co-defendants in
nurse practitioner malpractice litigation. These professionals or institutions may
bear liability for granting nurse practitioners too much authority, or for failing
to appropriately supervise their practice. Thus, they should be conversant
with the issues surrounding the professional activities of nurse practitioners.
Nurse practitioners will continue to play a critical role in the healthcare industry.
As the legal and regulatory framework of advanced nursing practice changes,
mitigating the risk of professional liability claims for nurse practitioners and
defending claims of negligence when they occur will remain a challenge.
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7
Claims Analysis
Database and Methodology
This study presents and analyzes professional liability claims brought against
CNA-insured nurse practitioners for events that occurred between January 1,
1998 and December 31, 2008. During this period, 1,799 claims were reported.
Of these, 1,092 claims were excluded from the study, leaving 707 open and
closed claims. Claims were excluded for one or more of the following reasons:
-The reported incident closed with no indemnity
or expense payment.
-Deposition assistance was the only service provided.
-Legal assistance for protection of the nurse practitioner’s
license was the only service provided.
-The claim was a drug-related class action lawsuit.
-The claim did not involve professional liability.
*
Throughout this section of the document, frequency refers to the number
of open and closed claims with the specified attribute, such as a particular
allegation, location or specialty. Indemnity payments are monies paid for the
settlement or judgment of a claim by CNA. Expenses are monies paid by
CNA for the investigation, management and/or defense of a claim. Severity
refers to the average paid indemnity for closed claims that included indemnity
payments.
When drawing conclusions from the data, the following inherent limitations
should be noted:
-The database includes only CNA-insured nurse practitioners, which
may not represent the entire population of nurse practitioners.
-Indemnity and expense payments include only monies paid by CNA
on behalf of its insured nurse practitioners. Other possible sources of
payment related to a claim – such as employer-based coverage – are
not included in the data.
-Coverage for indemnity payments is generally limited by the policy
to $1 million, whereas judgments against a defendant may be higher.
1
* Nurse practitioners continue to be named in drug-related class action lawsuits. During the study
period, more than 20 such actions were initiated, with associated expenses exceeding $300,000.
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8
Ultimate Severity of Claims by Accident Year
This section is based on data extracted from our actuarial review and provides
best estimates of claim severity over time. Ultimate claim counts and severity
are projected using actuarial methods based on historical development patterns. Optimally, ultimate values should not change over time. However, as
no model can predict claim settlement with precision, ultimate values may
increase or decrease at each evaluation.
Figure 1a shows that the average indemnity payment has increased over the
past 10 years. It was approximately $168,600 in 1999 and is projected to be
$189,300 in 2008. Despite some volatility, the average appears to be increasing at a rate of 2.3 percent per year. As shown in Figure 1b, the average
expense payment has also increased over the past 10 years. It was approximately $28,500 in 1998 and is projected to be $42,900 in 2008. The average
appears to be increasing at a rate of 2.9 percent per year.
1a
Ultimate Average Indemnity
by Accident Year *
(with Trend Line)
$250,000
$200,000
$150,000
$100,000
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
1b
1998
* Accident year is the year the event occurred.
1998
$50,000
Ultimate Average Expense
by Accident Year *
(with Trend Line)
$50,000
$40,000
$30,000
$20,000
$10,000
* Accident year is the year the event occurred.
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9
Analysis of Claims by Claim Category
“Claim category” refers to whether the claim is open or closed, an important
distinction when determining patterns and trends related to claim frequency
and severity.
Figure 2 includes the percentages of open and closed claims, the indemnity
and/or expense payments, and the amount of case reserves for open claims
before the exclusion criteria were applied. A total of $89.7 million has been
paid or reserved for the 1,799 open and closed claims. More than $7.5 million
has been paid for investigation and management of claims closed with no
indemnity payment, and more than $5 million has been paid for investigation
and management of open claims. (An indemnity payment may be incurred
for open claims because a partial indemnity or a component of the indemnity,
such as medical costs, has been paid prior to closure. Alternatively, the full
indemnity has been paid, but administrative activities to close the claim have
not been completed.)
Claims by Claim Category
2
Claim Category
Percent of
Reported
Claims*
Total Paid
Indemnity
Total Paid
Expense
Total Case
Reserve
Total Paid
Indemnity,
Expense
and
Reserves
Closed with expense only
35.4%
$0
$7,567,044
$0
$7,567,044
Closed with indemnity payment
13.6%
$39,067,185
$12,415,994
$0
$51,483,178
Closed without payment
34.6%
$0
$0
$0
$0
Open
16.5%
$667,003
$5,052,576
$24,919,323
$30,638,902
Total
100.1%
$39,734,188
$25,035,614
$24,919,323
$89,689,124
* Total equals 100.1 due to rounding.
A total of $89.7 million has been paid or reserved
for open and closed claims, including more than $7.5
million paid in expenses for claims closed with no
indemnity payment.
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10
Analysis of Claims by Clinical Specialty
As indicated in Figure 3a, nurse practitioners specializing in adult/geriatric,
family and pediatric/neonatal medicine account for 84.3 percent of CNA open
and closed claims. This finding is consistent with the previous study.
Pediatric/neonatal closed claims have the highest average paid indemnity.
This level of severity may reflect the need for complex and prolonged medical services following injury to a child or infant. While obstetrics/gynecology
closed claims are typically associated with the highest severity, that is not the
case for nurse practitioners included in this study. In general, nurse practitioners work with patients in prenatal and postpartum care settings, rather
than in labor and delivery. This may explain why closed claims for nurse practitioners in obstetrics/gynecology have a lower average paid indemnity than
pediatric/neonatal claims.
Student 1.0%
Psychiatric 5.2%
Adult/geriatric 52.2%
Obstetrics/
gynecology 9.5%
3a
Family medicine and
Pediatric/neonatal 32.1%
Distribution by
Clinical Specialty
(Open and Closed Claims)
Clinical Specialty
Percent of
Reported
Claims
Percent of
Policies 1998-2008
Adult/geriatric
52.2%
27.1%
Family medicine and Pediatric/neonatal*
32.1%
39.8%
Obstetrics/gynecology
9.5%
2.9%
Psychiatric
5.2%
8.6%
Student
1.0%
21.6%
Total
100.0%
100.0%
Clinical Specialty
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
* Policy information is not available individually for these two specialties.
Severity by Clinical Specialty
(Closed Claims
with Indemnity Payment)
3b
Pediatric/neonatal
4.7%
$318,150
Obstetrics/gynecology
7.0%
$193,900
Family medicine
28.2%
$169,227
Psychiatric
4.7%
$168,392
Adult/geriatric
54.9%
$146,586
Student*
0.5%
$60,000
* Severity is based on three or fewer closed claims.
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11
Analysis of Claims by Location
The most frequent location where adverse events occured was the medical
care office, followed by non-hospital-based clinics. These findings are consistent with the previous study. The third most frequent location for a claim was
nursing homes, a category that has been added to the current study and will
be closely monitored.
Although adverse events that occurred at freestanding urgent care centers
and within inpatient hospital services have the highest severity, the four claims
with a $1 million indemnity payment are associated with adverse events that
occurred either in an emergency department, non-hospital-based clinic or
medical care office.
The severity for some locations differed considerably between the previous
and current studies. It appears that this is due to a weak statistical relationship between location and severity.
All other locations 6.5%
4a
Emergency
department 5.7%
Distribution by Location
(Open and Closed Claims)*
Location
Percent of
Open and Closed
Claims
Medical care office
42.4%
Clinic - non-hospital-based
17.8%
Nursing home
12.2%
Prison health
8.2%
Hospital - inpatient services
7.2%
Emergency department
5.7%
Hospital - inpatient
services 7.2%
Prison health 8.2%
Severity by Location
(Closed Claims
with Indemnity Payment)
Location
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
Freestanding urgent care*
0.9%
$370,000
Hospital - inpatient services
6.1%
$228,219
Clinic - non-hospital-based
26.3%
$191,546
Medical care office
38.5%
$182,263
Emergency department
5.2%
$138,028
Hospital - outpatient services
1.9%
$120,823
Patient's home
2.3%
$119,894
Other*
0.9%
$112,500
Nursing home
14.1%
$89,510
Prison health
3.8%
$30,969
* Severity is based on three or fewer closed claims.
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Clinic - non-hospital-based 17.8%
Nursing home 12.2%
* Figure 4a excludes locations with less than 5 percent of open and closed claims.
4b
Medical care office 42.4%
12
Analysis of Claims by Injury
When a claim involved multiple alleged injuries, the primary or most serious injury was identified as the dominant injury. The most frequent injury is
death, which occurred in 40.5 percent of open and closed claims. Cancer
claims are a distant second at 6.8 percent. The three most expensive injuries among closed claims are fetal/infant brain injury related to birth, brain
injury not related to birth and paralysis. Paralysis and brain injury were also
among the most expensive injuries in the previous study. Wrongful death
claims resulted in an average paid indemnity of $189,956, an increase from
$176,550 in the prior study. Many types of injuries occurred infrequently.
These are included in the pie chart as “All other injuries.”
Wrongful death 40.5%
All other
injuries 38.6%
5a
Emotional distress/
psychological
harm 3.8%
Cancer 6.8%
Infection/abscess/sepsis 5.5%
Loss of organ or
organ function 4.8%
Distribution by Injury
(Open and Closed Claims)*
Injury
Percent of
Open and Closed
Claims
Wrongful death
40.5%
Cancer
6.8%
Infection/abscess/sepsis
5.5%
Loss of organ or organ function
4.8%
Emotional distress/psychological harm
3.8%
Fracture
3.1%
Neurological deficit/injury
3.0%
Pain and suffering
2.4%
Allergic reaction/anaphylaxis
2.0%
* Figure 5a excludes injuries that account for less than 2 percent of open and closed claims.
The three most expensive injuries among closed
claims are fetal/infant brain injury related to birth,
brain injury not related to birth and paralysis.
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13
Severity by Injury
(Closed Claims with
Indemnity Payment)*
5b
Injury
Percent of
Closed
Claims with
Indemnity Payment
Average
Paid
Indemnity
Fetal/infant birth-related brain injury**
0.5%
$850,000
Brain injury other than birth-related
2.8%
$611,111
Paralysis**
1.4%
$350,000
Cancer
7.5%
$212,688
Loss of organ or organ function
5.2%
$194,318
Wrongful death
40.4%
$189,956
Cardiac condition
1.9%
$168,550
$161,667
Dislocation**
1.4%
Neurological deficit/injury
5.2%
$139,607
Cerebral vascular accident/stroke**
1.4%
$118,333
Scar(s)/scarring
2.3%
$117,500
Pain and suffering
1.9%
$117,250
Allergic reaction/anaphylaxis
3.8%
$82,294
Seizure**
0.5%
$80,500
Infection/abscess/sepsis
5.2%
$79,324
Eye injury/vision loss**
1.4%
$78,333
Emotional distress/psychological harm
2.8%
$75,792
Laceration/tear
3.3%
$60,071
Appendicitis
1.9%
$55,938
Amputation**
0.9%
$50,000
* Figure 5b excludes closed claims with average paid indemnity of less than $50,000.
** Severity is based on three or fewer closed claims.
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14
Analysis of Claims by Disability
The categories of disability in Figures 6a and 6b describe the extent of harm
caused by the alleged injury. While over 40 percent of the claims involved
a patient death, permanent total disability has the highest severity. The significant severity of claims related to permanent total and permanent partial
disability reflects ongoing costs to support the needs of disabled claimants.
No disability 4.5%
Permanent total
disability 4.8%
Temporary total disability 1.0%
Death 40.5%
Outcome not
available 6.1%
6a
Distribution by Disability
(Open and Closed Claims)
Permanent partial disability 25.7%
Temporary partial disability 17.4%
Injury Outcome
Percent of
Open and Closed
Claims
Death
40.5%
Permanent partial disability
25.7%
Temporary partial disability
17.4%
Outcome not available
6.1%
Permanent total disability
4.8%
No disability
4.5%
Temporary total disability
1.0%
Total
100.0%
Severity by Disability
(Closed Claims with
Indemnity Payment)
6b
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
Permanent total disability
5.2%
$335,864
Death
40.4%
$189,956
Permanent partial disability
31.9%
$180,596
Temporary partial disability
20.2%
$64,922
Temporary total disability*
1.4%
$8,250
No disability*
0.9%
$5,250
Injury Outcome
* Severity is based on three or fewer closed claims.
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Analysis of Claims by Allegation
The predominant allegations for open and closed claims are related to diagnosis, treatment and medication. The data reflect minimal change since the
previous study. Allegations that the nurse practitioner provided services outside the designated scope of practice (based on regulation or protocol) are
infrequent, but have the highest severity among the closed claims.
All other allegations 4.6%
Monitoring 4.0%
7a
Distribution by Allegation
(Open and Closed Claims)
Patient assessment 6.4%
Allegation Category
Percent of
Open and Closed
Claims
Diagnosis
39.0%
Treatment
28.3%
Medication
17.7%
Patient assessment
6.4%
Monitoring
4.0%
Practitioner conduct
1.4%
Scope of practice
1.1%
Patient's rights
0.7%
Other
0.7%
Documentation
0.4%
Equipment
0.3%
Total
100.0%
Allegation Category
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
Scope of practice*
0.9%
$450,000
Treatment 28.3%
Medication 17.7%
Severity by Allegation
(Closed Claims
with Indemnity Payment)
7b
Diagnosis 39.0%
Patient assessment
6.1%
$269,154
Diagnosis
46.0%
$186,168
Documentation*
0.9%
$162,500
Medication
18.3%
$147,554
Monitoring
2.3%
$114,400
Treatment
23.9%
$111,971
Equipment*
0.5%
$60,000
Practitioner conduct*
0.9%
$36,250
* Severity is based on three or fewer closed claims.
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Analysis of Allegations Related to Diagnosis
The most frequent and severe diagnosis-related allegation was failure to
correctly diagnose, accounting for more than 71.4 percent of these claims.
Significant variation in the services that nurse practitioners provide may
account for the severity and range of diagnostic claims. This variation is
related to state-specific regulations and organization-specific protocols.
Failure to obtain
tests 13.0%
Failure to correctly
diagnose 71.4%
Delay in
establishing
diagnosis 15.6%
8a
Distribution of Allegations
Related to Diagnosis
(Open and Closed Claims)
Allegations: Diagnosis
Percent of
Open and Closed
Claims
Failure to correctly diagnose
71.4%
Delay in establishing diagnosis
15.6%
Failure to obtain tests
13.0%
Total
100.0%
Severity of Allegations
Related to Diagnosis
(Closed Claims
with Indemnity Payment)
8b
Allegations: Diagnosis
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
Failure to correctly diagnose
65.3%
$213,199
Failure to obtain tests
20.4%
$170,088
Delay in establishing diagnosis
14.3%
$85,571
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Analysis of Allegations Related to Treatment
The second most frequent category of allegation for open and closed claims
relates to treatment. Within treatment-related allegations, failure to order or
obtain appropriate consultation/referral has the highest severity, with an average paid indemnity of $305,142. This amount is more than twice the average
paid indemnity associated with the next highest category, improper management of a medical patient or medical complication. The severity may indicate
that there was a perception that the nurse practitioner was practicing outside
the intended scope of practice.
All other treatment
allegations 15.0%
9a
Distribution of Allegations
Related to Treatment
(Open and Closed Claims)
Allegations: Treatment
Delay in
treatment 8.0%
Failure to properly
treat 26.5%
Percent of
Open and Closed
Claims
Failure to properly treat
established or identified diagnosis/illness
26.5%
Improper technique or negligent performance of treatment, resulting in injury
19.5%
Improper management of medical patient
or medical complication
13.0%
Failure to order or obtain appropriate
consultation/referral
9.5%
Failure to treat symptoms/illness/
disease in accordance with established
standards/protocols/pathways
8.5%
Delay in treatment/care
8.0%
Improper management of pregnancy, labor
and delivery, or obstetrical complication
4.0%
Treatment - other
3.0%
Failure to order/perform necessary treatment
3.0%
Improper management of behavioral
health/mental health patient
or behavioral health complication
2.5%
Delay in ordering or implementing
indicated/appropriate treatment
2.5%
Total
100.0%
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Substandard
treatment 8.5%
Failure to consult 9.5%
Improper
technique/negligent
performance 19.5%
Improper management 13.0%
18
Severity of Allegations
Related to Treatment
(Closed Claims
with Indemnity Payment)
9b
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
Failure to order or obtain appropriate
consultation/referral
15.7%
$305,142
Improper management of medical
patient or medical complication
9.8%
$130,200
Failure to properly treat established or
identified diagnosis/illness
31.4%
$102,915
Failure to order/perform
necessary treatment*
2.0%
$93,000
Delay in treatment/care*
5.9%
$91,667
Improper management of behavioral
health/mental health patient
or behavioral health complication*
2.0%
$50,000
Failure to treat symptoms/illness/
disease in accordance with established
standards/protocols/pathways*
3.9%
$39,750
Improper technique or negligent performance of treatment, resulting in injury
29.4%
$31,617
Allegations: Treatment
* Severity is based on three or fewer claims.
Failure to order or obtain appropriate consultation/referral
has the highest severity of the treatment-related
allegations, with an average paid indemnity of $305,142.
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Analysis of Allegations Related to Medication
More than 80 percent of medication errors are prescription-related. Notably,
one-third involve prescribing the wrong medication.
Administration missed dose 5.6%
10a
Distribution of Allegations
Related to Medication
(Open and Closed Claims)
Administration wrong dose 5.6%
Allegations: Medication
Percent of
Open and Closed
Claims
Prescription - wrong medication
33.6%
Prescription - wrong dose
16.0%
Prescription - failure to properly
discontinue medication
14.4%
Prescription - incompatible/contraindicated/
interactive medications
9.6%
Administration - wrong dose
5.6%
Administration - missed dose
5.6%
Prescription - wrong route
3.2%
Prescription - missed dose*
3.2%
Administration - wrong medication
3.2%
Administration - wrong route
2.4%
Prescription - wrong patient
1.6%
Administration - incompatible/
contraindicated/interactive medications
0.8%
Administration - failure to properly
discontinue medication
0.8%
Total
100.0%
Prescription incompatible/
contraindicated/
interactive
medications 9.6%
Severity of Allegations
Related to Medication
(Closed Claims
with Indemnity Payment)
Allegations: Medication
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
12.8%
$276,000
Prescription - failure to properly
discontinue medication
Administration - wrong dose*
5.1%
$275,000
Prescription - wrong medication
35.9%
$174,561
Prescription - wrong patient*
2.6%
$150,000
Administration - wrong route*
2.6%
$150,000
$84,085
Prescription - wrong dose
23.1%
Administration - missed dose*
5.1%
$81,250
Prescription - wrong route*
5.1%
$46,250
Prescription - incompatible/contraindicated/
interactive medications*
7.7%
$23,000
* Severity is based on three or fewer claims.
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Prescription - wrong
medication 33.6%
Prescription wrong dose 16.0%
Prescription - failure to properly
discontinue medication 14.4%
* Refers to situations where a failure to renew a prescription resulted in one or more missed doses.
10b
All other medication
errors 15.2%
20
Analysis of Injuries Resulting in Death
As indicated in Figure 5a, wrongful death occurred in 40.5 percent of open
and closed claims. Almost half of these claims are related to infection, cardiac
condition or cancer. Of these most frequent injuries, cardiac condition and
cancer also have high severity, as seen in Figure 11b.
All other injuries 19.6%
Maternal
obstetrical-related
injury 3.5%
Infection/abscess/sepsis 23.1%
11a
Loss of organ or
organ function 3.5%
Complication from
surgery, treatment,
procedure,
medication 3.8%
Embolism 3.8%
Pneumonia/respiratory
infection 4.2%
Emotional distress/
psychological harm 5.2%
Cardiac
condition 15.0%
Cancer 11.2%
Bleeding/hemorrhage 7.0%
Distribution of Injuries
Resulting in Death
(Open and Closed Claims)*
Injury Related to Death
Percent of
Open and Closed
Claims
Infection/abscess/sepsis
23.1%
Cardiac condition
15.0%
Cancer
11.2%
Bleeding/hemorrhage
7.0%
Emotional distress/psychological harm
5.2%
Pneumonia/respiratory infection
4.2%
Embolism
3.8%
Complication from surgery, treatment,
procedure, medication
3.8%
Loss of organ or organ function
3.5%
Maternal obstetrical-related injury
3.5%
Fracture
2.4%
Aneurysm
2.1%
Cerebral vascular accident/stroke
2.1%
Other
2.1%
* Figure 11a excludes injuries related to less than 2 percent of the claims.
Almost half of the injuries that resulted in death are
related to infection, cardiac condition or cancer.
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Severity of Injuries
Resulting in Death
(Closed Claims
with Indemnity Payment)*
11b
Percent of
Closed
Claims with
Indemnity
Payment
Average
Paid
Indemnity
Complication from surgery, treatment,
procedure, medication**
3.5%
$483,333
Appendicitis**
1.2%
$482,500
Homicide**
1.2%
$400,000
Cancer
10.5%
$288,810
Cardiac condition
22.1%
$250,756
Injury Related to Death
Seizure**
1.2%
$250,000
Emotional distress/psychological harm**
2.3%
$192,500
Infection/abscess/sepsis
17.4%
$162,893
Maternal obstetrical-related injury**
2.3%
$162,500
Bleeding/hemorrhage
7.0%
$147,500
Brain injury other than birth-related**
2.3%
$143,500
Loss of organ or organ function
4.7%
$142,500
Allergic reaction/anaphylaxis**
2.3%
$140,000
Unspecified injury**
1.2%
$112,500
Pneumonia/respiratory infection**
3.5%
$91,000
$84,861
Embolism
7.0%
Cerebral vascular accident/stroke**
1.2%
$77,500
Other**
1.2%
$60,000
Fracture**
2.3%
$52,500
* Figure 11b excludes injuries with average paid indemnity of less than $50,000.
** Severity is based on three or fewer claims.
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Analysis of Closed Claims with
the Highest Indemnity Payments
The average indemnity payment by CNA on behalf of its nurse practitioner
insureds is approximately $165,000. However, 25 percent of these indemnity
payments exceed $250,000. CNA typically issues nurse practitioner professional liability policies with limits of liability for indemnity payments of $1 million per occurrence. Expenses are covered in addition to the indemnity limit.
The structure of the policies thus affects the average indemnity payment for
claims in the highest severity category.
Figure 12b displays closed claims with indemnity payments equal to or greater than $500,000. Six of the claims are related to diagnosis and four are
related to medication errors. Of the four claims with the $1 million indemnity
payment, three are related to diagnosis and one to patient assessment. While
these high-severity claims are distributed fairly evenly across specialties, they
occurred most frequently in an outpatient setting.
Analysis by Severity
(Closed Claims
with Indemnity Payment)
12a
Indemnity Payment
Percent of
Closed
Claims with
Indemnity
Payment*
Average
Paid
Indemnity
Average
Paid
Expense
$45,815
Less than $250,000
74.6%
$64,078
$250,000 - $500,000
18.3%
$352,430
$72,985
Greater than $500,000
7.0%
$747,000
$78,412
Total/Average
99.9%
$164,968
$53,085
* Total equals 99.9 percent due to rounding.
The average indemnity payment by CNA on behalf of its
nurse practitioner insureds is approximately $165,000.
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23
12b
Closed Claims with
Indemnity Payment
of $500,000 or Greater
Allegation
Injury
Failure to diagnose and treat lung cancer
Wrongful
death
Failure to diagnose endometrial cancer
Paid
Indemnity
Specialty
Location
$1,000,000
Family
medicine
Clinic
Cancer
$1,000,000
Obstetrics/
gynecology
Medical
care office
Failure to diagnose cardiac disease, leading
to myocardial infarction and death
Wrongful
death
$1,000,000
Adult/
geriatric
Clinic
Failure to properly assess intracranial
bleeding in infant, leading to severe
developmental and cognitive delays
Brain injury
$1,000,000
Pediatric/
neonatal
Emergency
department
Incorrectly prescribed weight-loss medication, resulting in cerebral hemorrhage
Brain injury
$855,000
Adult/
geriatric
Clinic
Failure to properly assess patient
during prenatal care, resulting
in child born with cerebral palsy
Birth-related
brain injury
$850,000
Pediatric/
neonatal
Medical
care office
Failure to properly discontinue
prescription of medication, resulting
in permanent disability
Brain injury
$775,000
Adult/
geriatric
Hospital inpatient
services
Failure to diagnose bacterial
endocarditis after several office visits
with recurrent complaints
Paralysis
$750,000
Adult/
geriatric
Clinic
Incorrect diagnosis of bursitis, resulting
in myocardial infarction and death
Wrongful
death
$650,000
Family
medicine
Freestanding
urgent care
Failure to assess medical history, resulting
in failure to diagnose Fournier's disease
Loss of organ
$625,000
Family
medicine
Clinic
Failure to seek appropriate consultation
following several office visits with recurrent
complaints of neurological deficits
Neurological
deficit/injury
$600,000
Family
medicine
Medical
care office
Failure to obtain consultation
following change in condition, resulting
in vegetative state
Brain injury
$550,000
Pediatric/
neonatal
Hospital –
inpatient
services
Failure to discontinue medication, resulting
in burns over 50 percent of the body
Scar(s)/
scarring
$550,000
Psychiatric
Clinic –
non-hospitalbased
Acted outside scope of practice
by ordering angiogram without physician
consultation, resulting in death
Wrongful
death
$500,000
Adult/
geriatric
Hospital –
inpatient
services
Incorrectly prescribed dose of medication,
resulting in infant death
Wrongful
death
$500,000
Pediatric/
neonatal
Medical
care office
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Risk Management Recommendations
The following risk management recommendations, which reflect the preceding claims analysis, are presented as a useful resource for nurse practitioners.
The list is not intended to be exhaustive. For additional strategies, see the
risk management offerings available at www.cna.com.
Insurance
Ensure that collaborating and supervising professionals, nurse partners, and
employing or contracting facilities maintain appropriate professional liability
insurance limits, as required by practice setting, state law and/or regulations.
Scope of Practice
Annually review state nurse practice acts and other pertinent state and/or
federal regulations defining the scope of practice for nurse practitioners.
Revise collaborative practice agreements and other documents accordingly.
Health Information Records
-Ensure that patient health information records are in compliance
with established standards of documentation.
-Retain patient health information records in accordance with
relevant state and federal law. In addition, consult the state-specific
recommendations promulgated by nurse practitioner professional
associations.
-Perform periodic audits of patient health information records
to identify departures from documentation standards and to
determine opportunities for improvement.
-Sequester the patient health information record if there is an incident
of concern. Patient health information released for legal reasons also
should be sequestered or maintained with limited access to avoid real
or alleged tampering or inappropriate late entries.
-Designate an individual within the practice who will manage
legal demands such as a request for patient health information,
a subpoena, or a summons and complaint.
Documentation
A complete health information record is the best legal defense. The following information and communications should be documented:
-discussions with the patient and/or responsible party regarding
diagnostic test results (both normal and abnormal), as well as recommendations for continued treatment and patient response to results
-informed consent or informed refusal of recommended treatment
and preceding discussions
-patient telephone encounters, including after-hours calls, with
the name of the person contacted, advice provided and actions
taken reflected in the written summary
-dated and signed receipt of test results, procedures, referrals and
consultations, along with a description of subsequent actions taken
-referrals for consultation or testing
-reviews and revisions of patient problem and medication lists
during every visit and with every change in diagnosis
C N A H ealth P ro N urse P ractitioner C laims A nalysis 19 9 8 - 2 0 0 8
25
-prescription refills authorized via telephone, including the name
of the pharmacy and pharmacist, and read-back of the prescription
-missed appointments, including all efforts to follow up with
the patient
-educational materials or references provided to the patient
-use of an interpreter and related contact information, recognizing
that the use of family members, especially children, is discouraged
Diagnosis and Treatment
-Diligently screen for, monitor and/or treat diseases known to
have high morbidity and mortality, such as diabetes, heart disease
and cancer.
-Utilize available clinical practice guidelines or protocols when
establishing a diagnosis and providing treatment, documenting
the justification for deviations from guidelines or protocols.
-Seek timely consultation and advice regarding patients with
recurring complaints and/or signs and symptoms that do not
respond to the prescribed treatment.
-Document the decision-making process that led to the diagnosis
and treatment plan.
-Notify patients when screening is due and follow up if patients
do not respond, documenting all communications.
Medication Management
-Include the purpose of the medication as part of the prescription
to mitigate the risk of drug error.
-Avoid error-prone abbreviations and never abbreviate medication
indications, name, dose, frequency or route.
-Limit telephone refills to one and require a patient evaluation in
the office before providing additional refills.
-Identify look-alike and sound-alike drugs used in the practice and
place adequate warnings on packaging.
-Avoid storing similar-looking drugs near one another to prevent
possible confusion.
-Remove drugs with similar-sounding names from the practice
formulary, if possible.
-Comply with established standards for educating patients and
families about prescriptions, including the purpose of the medication, potential side effects and indications for calling the nurse
practitioner.
-Maintain current drug reference materials and other resources that
provide information on medications, including potential interactions.
-Consult with physicians, pharmacists or evidence-based resources
as needed, to mitigate the risk of prescribing the wrong medication
or dosage, and to avoid drug interactions or contraindications.
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Conclusion
The findings of this claims analysis confirm that nurse practitioners continue
to be vulnerable to professional liability claims. Despite tort reform measures and innovative legal defense strategies, nurse practitioner claim severity
remains high, with average indemnity and expense payments trending upward since the publication of the previous study.
We hope that readers find this information useful, and that it inspires them
to examine their practices and develop effective strategies to protect themselves against the risks inherent in providing healthcare services. For more
information about liability issues, see the wide variety of CNA HealthPro risk
control publications available at www.cna.com.
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What is the relationship
between nurse practitioner
liability claims and
-level of professional
independence?
-p rescriptive authority?
-e ducational setting?
-experience with mentors?
29
Highlights from the NSO 2009
Nurse Practitioner Survey
Introduction
In 2005, CNA and NSO released the Nurse Practitioner Claim Study, 1994–
2004. The study analyzed 10 years of claims brought against nurse practitioners (NPs) in the CNA HealthPro-NSO program. The study of the nurse practitioner profession was the first of its kind, and it raised awareness regarding
the type and number of professional liability claims brought against nurse
practitioners, as well as strategies to mitigate risk.
The 2005 study answered many questions, but it also generated others. NSO
was repeatedly asked about the relationship between claims experience and
such variables as
-independent versus collaborative versus supervised practice
-level of prescriptive authority
-traditional educational environments (i.e., “brick and mortar”
institutions) versus on-line degree programs
-mentored versus non-mentored practice
NSO engaged Kretschman Research & Consulting to survey nurse practitioners on these and associated issues. The survey participants included nurse
practitioners who have participated in the NSO insurance program, comprising those who have and who have not experienced claims. Key survey findings are excerpted in the following pages. Because the charts are labeled as
they appear in the full survey, chart numbering is not always sequential. The
NSO survey is available at www.nso.com/NPclaimstudy2009.
H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
30
Survey Methodology
Kretschman Research & Consulting created the questionnaire, conducted
the interviews, analyzed the results and presented the findings to NSO. The
survey compared the demographics, educational preparation, clinical experience and practice conditions of nurse practitioners who have and have not
been the subject of a claim. The survey was conducted during the months of
June and July 2009.
For the purposes of this survey, the definition of nurse practitioner includes
clinical nurse specialists, except where clinical nurse specialists are cited separately. Please note that registered nurses, certified registered nurse anesthetists and certified nurse midwives were not included.
All nurse practitioners actively insured by NSO were eligible to participate in
the survey. Of the approximately 25,000 nurse practitioners invited to participate, 1,380 were identified as having had a professional liability claim filed
with NSO/CNA in the past five years. In addition to actively insured nurse
practitioners, the sample included nurse practitioners with an incident in the
same timeframe who have since not renewed their CNA/NSO policies.
The findings are based upon self-reported information and thus may be
skewed due to respondents’ perceptions and recollections of the requested
information. The chart below delineates the response rates for the survey:
Description
Total
Total responses
3,354
Disqualified because of duplication or
incompleteness
317
Non-claim responses
2,750
Claim responses
287
Total claim and non-claim responses
3,037
Usable response rate
12.8%
H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
31
Summary of Findings
-Traditional on-site versus on-line educational environment: Regardless of
claim status, a university or college on-site program was the predominant
educational resource for obtaining nurse practitioner designation. (Q2)
-State regulations governing practices: Nurse practitioners with claims
were more likely than nurse practitioners without claims to respond that
their state regulations require direct physician supervision. (Q8)
-Mentored versus non-mentored during the first two years of advanced
practice: Working with a mentor did not decrease the likelihood of having a claim. (Q14)
-Level of prescriptive authority: Nurse practitioners with claims have less
prescriptive authority than those without claims. (Q20)
Other findings include the following:
-Nurse practitioners with claims and nurse practitioners without claims
recalled that nearly the same number of clinical hours were required in
their nurse practitioner program. (Q6)
-Approximately 82 percent of the nurse practitioners with claims had
practiced 10 years or less, compared with 63 percent of the nurse practitioners in the non-claim group. (Q13)
-At the time of the incident, over half of the nurse practitioners had been
working in the specified position less than four years, while more than
two-thirds had been working in this position six years or less. (Q19)
-Nurse practitioners as a whole typically see an average of 16 patients
per day while nurse practitioners with claims report having seen more
than 18 patients per day at the time of the incident. (Q22)
-Most nurse practitioners with claims reported using handwritten medical
records at the time of the incident. (Q27)
H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
32
NSO Survey Excerpts
Demographics
Nursing Professional Type
Percent of
Respondents
with Claims
Percent of
Respondents
with No Claims Total
Percent (Base = 287)
(Base = 2,750)
(Base = 3,037)
Nurse Practitioner
90.6%
95.0%
94.6%
Clinical Nurse Specialist
8.0%
4.9%
5.2%
Other
1.4%
0.1%
0.2%
Total
100%
100%
100%
Percent of
Respondents
with Claims
Percent of
Respondents
with No Claims
Total
Percent Gender
(Base = 235)
(Base = 2,742)
(Base = 2,977)
Male
14.5%
6.6%
7.2%
Female
85.5%
93.4%
92.8%
Total
100%
100%
100%
Percent of
Respondents
with Claims
Percent of
Respondents
with No Claims
Total
Percent Age*
* Due to rounding, totals are slightly
over or under 100 percent. (Base = 235)
(Base = 2,742)
(Base = 2,977)
18 – 29
0.0%
4.3%
3.9%
30 – 49
36.2%
43.4%
42.8%
50 – 64
57.9%
49.3%
49.9%
65 or over
6.0%
3.1%
3.3%
Total
100.1%
100.1%
99.9%
Percent of
Respondents
with Claims
Percent of
Respondents
with No Claims
Total
Percent Highest Education Level Completed*
(Base = 235)
(Base = 2,742)
(Base = 2,977)
Associate’s Degree (AA/AS/AND)
2.1%
1.3%
1.3%
Bachelor’s Degree (BA/BS/BSN)
3.8%
2.7%
2.8%
Master’s Degree (MA/MS/MSN)
84.7%
90.4%
90.0%
Doctoral Degree (PhD/DNS/DNP/JD)
9.4%
5.5%
5.8%
Total
100%
99.9%
99.9%
Percent of
Respondents
with Claims
Percent of
Respondents
with No Claims
Total
Percent * Due to rounding, some totals are
slightly under 100 percent. Location of Practice
(Base = 233)
(Base = 2,728)
(Base = 2,961)
22.2%
Rural
30.0%
21.6%
Suburban
43.8%
40.9%
41.2%
Urban
26.2%
37.5%
36.6%
Total
100%
100%
100%
H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
33
Nurse Practitioner Education/Preparation
Eighty-eight percent of all nurse respondents and 89 percent of claim respondents stated that they used an on-site university program to achieve their nurse
practitioner designation. Only 5 percent of all nurse practitioners and 6 percent of claim respondents reached nurse practitioner status using on-line
programs alone.
Regardless of their claim history, survey respondents
predominantly earned their nurse practitioner designation
through an on-site university or college program.
Q2
Nurse Practitioner
Education/Preparation
How did you earn your NP designation?
0%
Community college program 1%
1%
Hospital-based program
1%
2%
1%
89%
88%
88%
University/college on-site program
6%
5%
5%
On-line program
0%
None 0%
0%
Other (please specify)
■ Claim (Base=287)
■ Non-claim (Base=2,750)
■ Total (Base=3,037) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
4%
5%
5%
34
Clinical Specialty
Approximately 50 percent of the nurse practitioners who completed the
survey are certified or licensed to work in family medicine. For most specialties, the proportion of nurse practitioners with and without claims is relatively
equal. Exceptions to this trend include family medicine and pediatrics. In
family medicine, there is a higher proportion of nurse practitioners with claims
(59 percent versus 49 percent) and in pediatrics, a significantly lower proportion of nurse practitioners with claims (3 percent versus 7 percent).
Q3
NURSE PRACTITIONER Specialty
In what specialty area(s) are you certified or licensed as an NP? (Check all that apply.)
22%
24%
24%
Adult care
Family medicine
49%
50%
5%
6%
6%
Gerontology
Neonatal
Obstetrics/perinatal
0%
1%
1%
3%
2%
2%
Oncology
0%
1%
1%
Occupational health
0%
1%
1%
Pediatrics
3%
7%
7%
13%
10%
11%
Behavioral health
Women’s health (excludes obstetrics)
Other (please specify)
59%
5%
5%
5%
7%
9%
9%
■ Claim (Base=287)
■ Non-claim (Base=2,750)
■ Total (Base=3,037) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
35
Clinical Hours Required in Nurse Practitioner Programs
More than half of the nurse practitioners were required to spend between
400 and 800 clinical hours in their nurse practitioner program. The group of
nurse practitioners who recalled needing less than 400 clinical hours was
slightly smaller than the group who recalled needing more than 800 hours
(20 percent and 23 percent, respectively).
Nurse practitioners with claims and nurse practitioners without claims recalled
spending nearly the same number of clinical hours in their nurse practitioner
program. On average, respondents spent 636 clinical hours in their nurse
practitioner program.
Q6
Nurse Practitioner Program
Clinical Hours Required
How many clinical hours were required in your NP program?
0 hours
Less than 100 hours
1%
1%
1%
3%
3%
3%
100 to 399 hours
16%
16%
26%
26%
26%
400 to 599 hours
26%
600 to 799 hours
800 to 999 hours
4%
1,000 hours or more
Other (please specify)
■ Claim (Base=209)
■ Non-claim (Base=2,265)
■ Total (Base=2,474) 19%
30%
30%
8%
7%
13%
13%
16%
4%
3%
3%
Note: the size of the base differs in the two Q6 charts because “Other specified” responses
were not included in determining the average number of required clinical hours.
Mean Number of Clinical
Hours Required in NURSE
PRACTITIONER Program
Average clinical hours required in NP program
Mean
■ Claim (Base=198)
■ Non-claim (Base=2,175)
■ Total (Base=2,373) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
695 hours
631 hours
636 hours
36
Years as a Registered Nurse
Prior to Becoming a Nurse Practitioner
Approximately 5 percent of the nurse practitioners were registered nurses
for less than two years before becoming certified as nurse practitioners.
About one-quarter of the nurse practitioners were registered nurses for less
than six years before receiving the nurse practitioner certification. More than
half of the nurse practitioners practiced for more than 10 years as a registered
nurse before acquiring their nurse practitioner designation.
On average, the respondents spent 13 years
practicing as registered nurses before
becoming certified as nurse practitioners.
Q7
Number of Years in Practice
as a Registered Nurse
How many years did you practice as a registered nurse before becoming certified to practice as an NP?
Less than 2 years
2 to 5 years
6 to 10 years
11 to 15 years
More than 15 years
4%
5%
5%
18%
19%
19%
18%
16%
16%
24%
24%
20%
35%
36%
41%
■ Claim (Base=282)
■ Non-claim (Base=2,750)
■ Total (Base=3,032) Mean Number of
Hours in Practice as
a Registered Nurse
Average years as an RN before becoming an NP
Mean
13.9 years
12.9 years
13.0 years
■ Claim (Base=282)
■ Non-claim (Base=2,750)
■ Total (Base=3,032) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
37
State Regulations Governing Practice
Nurse practitioners’ scope of practice requirements vary by state, with most
states permitting nurse practitioners to function collaboratively with physicians, rather than under direct physician supervision. Seventy-nine percent
of non-claim respondents, compared with 70 percent of claim respondents,
maintain that regulations in their state require nurse practitioners to practice
under the auspices of a collaborative practice agreement.
Nurse practitioners with claims were more likely than nurse practitioners without claims to say their state regulations require direct physician supervision
(9 percent versus 4 percent). For the respondents in the “Other” category,
the regulations governing their practice may have emanated from the military,
their school or another source.
Q8
State Regulations
Governing Practice
(At the time of the incident), state regulations governing my practice require(d): (Check one)
11%
15%
15%
No physician oversight
70%
Collaborative practice agreements
Direct physician supervision
Other (please specify)
■ Claim (Base=254)
■ Non-claim (Base=2,750)
■ Total (Base=3,004) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
4%
4%
3%
3%
9%
10%
79%
78%
38
Years of Experience as a Nurse Practitioner
Seventeen percent of those with claims had practiced less than two years at
the time of the incident. Half of the nurse practitioners with claims had been
practicing five years or less, compared with 36 percent in the non-claim group,
and 82 percent of the nurse practitioners with claims had practiced 10 years
or less, compared with 63 percent in the non-claim group. The experience
of nurse practitioners who have no claims more closely approximates a bellshaped curve.
On average, nurse practitioners with claims had 7.1 years of experience at
the time of the incident, while nurse practitioners without claims average 9.7
years of experience.
Q13
Years Practicing as
a Nurse Practitioner
(At the time of the incident), how many years have (had) you been an NP?
Less than 2 years
12%
12%
17%
2 to 5 years
32%
24%
25%
6 to 10 years
27%
28%
8%
11 to 15 years
20%
19%
10%
More than 15 years
33%
17%
16%
■ Claim (Base=249)
■ Non-claim (Base=2,750)
■ Total (Base=2,999) Average Number of Years
as A Nurse Practitioner
Mean
7.1 years
9.7 years
9.5 years
■ Claim (Base=249)
■ Non-claim (Base=2,750)
■ Total (Base=2,999) More years of experience as a nurse practitioner
may minimize the risk of an incident.
H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
39
Significance of a Mentor
Nurse practitioners with claims were more likely than nurse practitioners without claims to have been mentored during their first two years of advanced
practice (52 percent versus 37 percent). For those who had a mentor, the mentor was most often a physician. Nurse practitioners with claims were more
likely to have had a physician mentor than those with no claims (87 percent
versus 77 percent). Nurse practitioners without claims were more likely to
have had a nurse practitioner for a mentor (51 percent versus 30 percent).
Q14
Mentored versus
Non-Mentored During
the First Two Years of
Advanced Practice
Did you have a mentor during your first two years
of advanced practice?
Yes
52%
37%
39%
48%
No
63%
61%
■ Claim (Base=249)
■ Non-claim (Base=2,750)
■ Total (Base=2,999) Q15
Professional Background
of Mentor or Collaborator
Who was the mentor or collaborator? (Check all that apply)
Physician
77%
78%
30%
Nurse practitioner
Clinical nurse specialist
Other (please specify)
■ Claim (Base=129)
■ Non-claim (Base=1,025)
■ Total (Base=1,154) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
3%
7%
7%
5%
5%
5%
51%
49%
87%
40
Practicing Outside of Certification
Ninety percent of nurse practitioners who have claims say they do not practice outside of their area of certification. While 24 nurse practitioners with
claims admit to practicing outside of their specialty and working in a variety
of specialty areas, it is important to note that there is an even greater proportion of nurse practitioners without claims who say they work outside of
their specialty area (16 percent versus 10 percent). Half of the respondents
work in areas other than those specified in Chart Q18. The list of these specialties is available on pages 63 and 64 of the complete study, which is available at www.nso.com/NPclaimstudy2009.
Q17
Practicing Outside
of Certification
(At the time of the incident), are (were) you practicing in a specialty area in which you were not certified?
Yes
No
10%
16%
16%
90%
84%
84%
■ Claim (Base=240)
■ Non-claim (Base=2,750)
■ Total (Base=2,990) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
41
Q18
Clinical Specialties at the
Time of the Incident
(At the time of the incident), in what specialty area do (did) you practice? (Check one)
(Base=NPs who practice outside of certified specialty)
Adult care
8%
9%
Family medicine
9%
9%
Gerontology
13%
13%
7%
8%
17%
4%
Neonatal 0%
0%
Obstetrics/perinatal
1%
1%
Oncology
Pediatrics
4%
3%
4%
0%
8%
5%
5%
13%
10%
10%
Behavioral health
Women’s health (excludes obstetrics)
Other (please specify)
■ Claim (Base=24)
■ Non-claim (Base=430)
■ Total (Base=454) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
0%
6%
6%
29%
50%
49%
42
Years Working in Specified Position at Time of Incident
At the time of the incident, 53 percent of the nurse practitioners with claims
had worked in the particular position for less than four years, and 69 percent
had worked in the position for less than six years.
On average, nurse practitioners have worked in their current specialty area
position for 5.1 years. Nurse practitioners with claims had been working nearly
the same amount of time.
At the time of the incident, more than half of the
nurse practitioners had been working in the position
less than four years, and more than two-thirds
had been working in the position less than six years.
Q19
Years Working in This
Particular Position
(At the time of the incident), how many years have (had) you worked in this particular position?
25%
Less than 2 years
2 to 3.9 years
24%
24%
4 to 5.9 years
13%
13%
28%
16%
22%
20%
21%
6 to 10.9 years
6%
11 to 15 years
More than 15 years
30%
30%
8%
8%
3%
4%
4%
■ Claim (Base=240)
■ Non-claim (Base=2,750)
■ Total (Base=2,990) Average years working in this particular position
Average Years in Position
Mean
4.7 years
5.1 years
5.1 years
■ Claim (Base=240)
■ Non-claim (Base=2,750)
■ Total (Base=2,990) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
43
Prescriptive Authority
Nurse practitioners with claims are twice as likely as those without claims to
say they have no prescriptive authority. The nurse practitioners with claims
were also less likely than those without claims to say they had authority to prescribe Schedule II–V drugs (49 percent versus 60 percent) or Schedule III–V
drugs (21 percent versus 27 percent).
Q20
Level of Prescriptive
Authority
(At the time of the incident), what level of prescriptive authority do (did) you have? (Check all that apply)
32%
36%
36%
Non-scheduled prescription or legend drugs
(e.g., prescription medications such as antibiotics)
9%
Schedule V
13%
13%
21%
Schedule III-V
49%
Schedule II-V
None of the above
■ Claim (Base=237)
■ Non-claim (Base=2,726)
■ Total (Base=2,963) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
27%
26%
6%
6%
13%
60%
59%
44
Daily Patient Workload
Patient workload may contribute to malpractice exposure. Nurse practitioners with claims report greater daily patient workloads than those without
claims. While 45 percent of nurse practitioners without claims saw less than
15 patients per day, only 30 percent of those with claims tended to less than
15 patients daily at the time of the incident.
The nurse practitioners surveyed say they typically see an average of 16
patients per day, while those with claims reportedly saw an average of more
than 18 patients daily at the time of the incident. If we exclude nurse practitioners who do not see any patients at all, the nurse practitioners who had
claims were seeing an average of 19 patients per day.
Nurse practitioners typically see an average of 16 patients
per day, while nurse practitioners with claims report seeing
more than 18 patients per day at the time of the incident.
Q22
Daily Patient Workload
(At the time of the incident), what is (was) your
average patient workload per day?
0 (none)
3%
2%
2%
11%
Less than 10
16%
10 to 14
15 to 19
24%
24%
26%
20%
20%
20 to 24
19%
19%
23%
8%
7%
8%
25 to 29
30 to 39
40 or more
19%
19%
6%
6%
2%
2%
8%
4%
■ Claim (Base=239)
■ Non-claim (Base=2,750)
■ Total (Base=2,989) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
45
Average daily
patient workload
19.0 patients
16.5 patients
16.7 patients
Mean
■ Claim (Base=239)
■ Non-claim (Base=2,750)
■ Total (Base=2,989) Average daily
patient workload
(excluding NPs who do
not see any patients)
18.5 patients
16.2 patients
16.4 patients
Mean
■ Claim (Base=232)
■ Non-claim (Base=2,696)
■ Total (Base=2,928) Overtime
The large majority of nurse practitioners report that they were not required
to work overtime.
Q24
Overtime
(At the time of the incident, did) does your facility require you to work overtime?
Yes
No
■ Claim (Base=237)
■ Non-claim (Base=2,750)
■ Total (Base=2,987) H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
13%
17%
17%
87%
83%
83%
46
Electronic Medical Records
Nurse practitioners who had claims were twice as likely to have utilized handwritten medical records at the time of the incident than were nurse practitioners without claims (72 percent versus 36 percent). They were also less
likely to have been using a combination of electronic and handwritten medical records (16 percent versus 32 percent) at the time of the incident.
Q27
ELECTRONIC MEDICAL RECORDS
(At the time of the incident, did) does your facility
(Check one)
8%
Utilize electronic medical records
29%
27%
Utilize handwritten medical records
36%
38%
16%
Utilize a combination of electronic and
handwritten medical records
Other (please specify)
72%
32%
31%
4%
4%
4%
■ Claim (Base=237)
■ Non-claim (Base=2,750)
■ Total (Base=2,987) Seventy-two percent of nurse practitioners with
claims reported using handwritten medical records
at their facility when the incident occurred.
H ighlights from the N S O 2 0 0 9 N urse P ractitioner S ur v ey
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practitioners as well as nursing professionals, visit NSO on-line at www.nso.com or call 1-800-247-1500.
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