6 ways to reduce liability by improving doc-nurse teams


Positive relationships between physicians and nurses not only make for a smoother work environment, they also may reduce medical errors and lower the risk of lawsuits.

A recent study of closed claims by national medical malpractice insurer The Doctors Company found that poor physician oversight is a key contributor to lawsuits against nurses. Investigators analyzed 67 nurse practitioner (NP) claims from January 2011 to December 2016 and compared them with 1,358 claims against primary care physicians during the same time period.

Diagnostic and medication errors were the most common allegations against NPs, the study found, a trend that matched the most frequent allegations against primary care (internal medicine and family medicine) doctors. Top administrative factors that prompted lawsuits against nurses included inadequate physician supervision, failure to adhere to scope of practice, and absence of or deviation from written protocols.

The findings illustrate the importance of effective collaboration between physicians and NPs, said Darrell Ranum, vice president for patient safety and risk management for The Doctors Co. Below, legal experts share six ways to strengthen the physician-nurse relationship and at the same time, reduce liability:

1. Foster open dialogue. Cultivating a comfortable environment where nurses and physicians feel at ease sharing concerns and problems is a key step, says Louise B. Andrew, MD, JD, a physician and attorney who specializes in litigation stress management. A common scenario is a nurse who notices an abnormal vital sign but fails to mention it to the supervising physician because they feel they can handle it themselves or because they believe the doctor is too busy or too tired to be bothered, she said. The patient’s condition then worsens, resulting in a poor outcome that could have been avoided with better communication among providers. Delayed/wrong diagnosis accounted for 41% of claims against primary care physicians and 48% of claims against NPs in The Doctors Company study.

Dr. Louise B. Andrew is a physician and attorney who specializes in litigation stress management

Dr. Louise B. Andrew

“Nurses must not be afraid to ask doctors why they are doing something, and to inquire further if they see something they don’t understand,” Dr. Andrew said in an interview. Doctors, on the other hand, have an obligation, no matter how stressed or hurried they may be, not to send signals – bodily or otherwise – that they are not to be approached. That is a recipe for disaster.”

Set the tone early by exemplifying positive and clear communication, practicing good listening, and remaining empathetic, yet firm when making your needs known, Dr. Andrew advised.

“In the medical setting, you are always communicating for the benefit of the patient, and it is good to both keep this in mind, and to say it out loud,” she said.

2. Stick to the scope. When hiring an NP, make sure their scope of practice is clearly understood by all parties and respect their limitations, said Melanie L. Balestra, a Newport Beach, Calif., attorney and nurse practitioner who represents health providers.

Melanie Balestra, Newport Beach, California, lawyer and nurse practitioner

Melanie Balestra

Start by knowing your state’s scope of practice law for nurse practitioners. In 23 states and the District of Columbia, NPs have full authority to practice independently and can evaluate, diagnose, and manage treatment. In 15 states, NPs have reduced practice authority that requires a regulated collaboration agreement with a physician. In 12 states, NPs have restricted practice authority that requires supervision, delegation, or team management by a doctor.

Nurses practitioners must refrain from overstepping their authority, but physicians also must be careful not to ask too much of their NPs, experts stress. Ms. Balestra notes there is frequent confusion among doctors and NPs over how and whether scope of practice can be expanded as needed.

“This happens all the time,” Ms. Balestra said. “I get at least two questions on this every week [from nurses] asking, ‘Can I do this? Can I do that?’ ”

The answer depends on the circumstances, the nurse’s training, and the type of practice being broadened, Ms. Balestra said. For example, an NP in cardiology care may be allowed to perform more procedures in that field after internal training, but an NP who is trained in the care of adults can see pediatric patients only by going back to school.

“Know who you’re hiring, where their expertise lies, and where they feel comfortable,” she emphasized.

3. Preplan reviews. Early in the doctor-NP relationship, discuss and decide what type of medical cases warrant physician review, Mr. Ranum said. This includes agreeing on the type of patient conditions that will require a physician review and determining the types and percentage of medical records the doctor will evaluate, he said.

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