Nurse practitioners are at the forefront of a paradigm ... practitioners are at the forefront ......

Nurse practitioners 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 rec-

ommendations 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

C N A H E A LT H P R O N U R S E P R A C T I T I O N E R C L A I M S A N A LY S I S 19 9 8 - 2 0 0 8

cna HeaLtHPro nUrse Practitioner cLaims anaLysis 1998-2008

execUtive sUmmaryThis 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)

6


LegaL and regULatory environmentNurse 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 litiga-

tion 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 prac-

tices in which a nurse practitioner may engage. Others define the scope of

practice through regulatory boards, which also may serve as disciplinary bod-

ies 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 health-

care 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.

7


cLaims anaLysis

Database and MethodologyThis 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.

8


Ultimate Severity of Claims by Accident YearThis 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 pat-

terns. 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 increas-

ing 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 approxi-

mately $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.

1b ULtimate average exPense by accident year* (with trend Line)

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

$10,000

$20,000

$30,000

$40,000

$50,000

* Accident year is the year the event occurred.

1a ULtimate average indemnity by accident year* (with trend Line)

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

$50,000

$100,000

$150,000

$200,000

$250,000

* Accident year is the year the event occurred.

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.)

2cLaims by cLaim category

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.

1b ULtimate average exPense by accident year* (with trend Line)

1a ULtimate average indemnity by accident year* (with trend Line)

10


Adult/geriatric 52.2%

Student 1.0%

Psychiatric 5.2%

Obstetrics/gynecology 9.5%

Family medicine and Pediatric/neonatal 32.1%

3adistribUtion 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%

* Policy information is not available individually for these two specialties.

3b

severity by cLinicaL sPeciaLty(closed claims with indemnity Payment)

Clinical Specialty

Percent of Closed

Claims with Indemnity Payment

Average Paid

Indemnity

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.

Analysis of Claims by Clinical SpecialtyAs 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 med-

ical 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 practi-

tioners work with patients in prenatal and postpartum care settings, rather

than in labor and delivery. This may explain why closed claims for nurse prac-

titioners in obstetrics/gynecology have a lower average paid indemnity than

pediatric/neonatal claims.

11


All other locations 6.5%

Emergencydepartment 5.7%

Hospital - inpatientservices 7.2%

Prison health 8.2% Clinic - non-hospital-based 17.8%

Medical care office 42.4%

Nursing home 12.2%

4adistribUtion 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%

* Figure 4a excludes locations with less than 5 percent of open and closed claims.

4b

severity by Location (closed claims with indemnity Payment)

Location

Percent of Closed


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


3adistribUtion 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%

* Policy information is not available individually for these two specialties.

Analysis of Claims by LocationThe most frequent location where adverse events occured was the medical

care office, followed by non-hospital-based clinics. These findings are consist-

ent 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 relation-

ship between location and severity.

12


All otherinjuries 38.6%

Cancer 6.8%

Wrongful death 40.5%

Infection/abscess/sepsis 5.5%

Emotional distress/psychological

harm 3.8%

Loss of organ ororgan function 4.8%

5adistribUtion by injUry (open and closed claims)*

Injury

Percent of Open

and Closed Claims


Cancer 6.8%


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.

Analysis of Claims by InjuryWhen a claim involved multiple alleged injuries, the primary or most seri-

ous 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 inju-

ries 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.”

The three most expensive injuries among closed claims are fetal/infant brain injury related to birth,

brain injury not related to birth and paralysis.

13


5adistribUtion by injUry (open and closed claims)*

Injury

Percent of Open

and Closed Claims


Cancer 6.8%




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.

5b

severity by injUry (closed claims with indemnity Payment)*

Injury

Percent of Closed


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

Dislocation** 1.4% $161,667

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.

14


No disability 4.5%

Permanent totaldisability 4.8%

Outcome not available 6.1%

Permanent partial disability 25.7%

Death 40.5%

Temporary partial disability 17.4%

Temporary total disability 1.0%

6adistribUtion by disabiLity (open and closed claims)

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%

6b

severity by disabiLity (closed claims with indemnity Payment)

Injury Outcome

Percent of Closed


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


Analysis of Claims by DisabilityThe 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 sig-

nificant severity of claims related to permanent total and permanent partial

disability reflects ongoing costs to support the needs of disabled claimants.

15


Patient assessment 6.4%

Diagnosis 39.0%

Treatment 28.3%

Medication 17.7%

Monitoring 4.0%

All other allegations 4.6%

7adistribUtion by aLLegation(open and closed claims)

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%

7b

severity by aLLegation(closed claims with indemnity Payment)

Allegation Category

Percent of Closed


Average Paid

Indemnity

Scope of practice* 0.9% $450,000

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


Analysis of Claims by AllegationThe predominant allegations for open and closed claims are related to diag-

nosis, treatment and medication. The data reflect minimal change since the

previous study. Allegations that the nurse practitioner provided services out-

side the designated scope of practice (based on regulation or protocol) are

infrequent, but have the highest severity among the closed claims.

16


Delay inestablishing

diagnosis 15.6%

Failure to correctly diagnose 71.4%

Failure to obtain tests 13.0%

8adistribUtion of aLLegations reLated to diagnosis (open and closed claims)

Allegations: Diagnosis

Percent of Open

and Closed Claims


Delay in establishing diagnosis 15.6%


Total 100.0%

8b

severity of aLLegations reLated to diagnosis (closed claims with indemnity Payment)


Percent of Closed


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

Analysis of Allegations Related to DiagnosisThe 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.

17


Improper technique/negligent performance 19.5%

Failure to properly treat 26.5%

Failure to consult 9.5%

Substandardtreatment 8.5%

Improper management 13.0%

Delay in treatment 8.0%

All other treatmentallegations 15.0%

9adistribUtion of aLLegations reLated to treatment (open and closed claims)

Allegations: Treatment

Percent of Open

and Closed Claims

Failure to properly treat established or identified diagnosis/illness 26.5%

Improper technique or negligent perfor-mance 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/pathways8.5%

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 complication2.5%

Delay in ordering or implementing indicated/appropriate treatment 2.5%

Total 100.0%

8adistribUtion of aLLegations reLated to diagnosis (open and closed claims)


Percent of Open

and Closed Claims


Delay in establishing diagnosis 15.6%


Total 100.0%

8b

severity of aLLegations reLated to diagnosis (closed claims with indemnity Payment)


Percent of Closed


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

Analysis of Allegations Related to TreatmentThe 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 aver-

age paid indemnity of $305,142. This amount is more than twice the average

paid indemnity associated with the next highest category, improper manage-

ment 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.

18


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.

9b

severity of aLLegations reLated to treatment (closed claims with indemnity Payment)


Percent of Closed


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


or behavioral health complication*2.0% $50,000


standards/protocols/pathways*3.9% $39,750

Improper technique or negligent perfor-mance of treatment, resulting in injury 29.4% $31,617

* Severity is based on three or fewer claims.

19


9b

severity of aLLegations reLated to treatment (closed claims with indemnity Payment)


Percent of Closed


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


or behavioral health complication*2.0% $50,000


standards/protocols/pathways*3.9% $39,750

Improper technique or negligent perfor-mance of treatment, resulting in injury 29.4% $31,617


Prescription - wrong dose 16.0%

Prescription -incompatible/

contraindicated/interactive

medications 9.6%

Prescription - failure to properly discontinue medication 14.4%

Administration -wrong dose 5.6%

Administration -missed dose 5.6%

All other medication errors 15.2%

Prescription - wrong medication 33.6%

10adistribUtion of aLLegations reLated to medication (open and closed claims)

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%

* Refers to situations where a failure to renew a prescription resulted in one or more missed doses.

10b

severity of aLLegations reLated to medication(closed claims with indemnity Payment)

Allegations: Medication

Percent of Closed


Average Paid

Indemnity

Prescription - failure to properly discontinue medication 12.8% $276,000

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

Prescription - wrong dose 23.1% $84,085

Administration - missed dose* 5.1% $81,250

Prescription - wrong route* 5.1% $46,250

Prescription - incompatible/contraindicated/interactive medications* 7.7% $23,000


Analysis of Allegations Related to MedicationMore than 80 percent of medication errors are prescription-related. Notably,

one-third involve prescribing the wrong medication.

20


Maternalobstetrical-related

injury 3.5%

All other injuries 19.6%

Loss of organ ororgan function 3.5%

Cardiaccondition 15.0%


Cancer 11.2%


Pneumonia/respiratoryinfection 4.2%

Embolism 3.8%

Complication fromsurgery, treatment,

procedure,medication 3.8%

Bleeding/hemorrhage 7.0%

11adistribUtion of injUries resULting in deatH (open and closed claims)*

Injury Related to Death

Percent of Open

and Closed Claims


Cardiac condition 15.0%

Cancer 11.2%



Pneumonia/respiratory infection 4.2%

Embolism 3.8%

Complication from surgery, treatment, procedure, medication 3.8%


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.

Analysis of Injuries Resulting in DeathAs 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.

Almost half of the injuries that resulted in death are related to infection, cardiac condition or cancer.

21


11adistribUtion of injUries resULting in deatH (open and closed claims)*


Percent of Open

and Closed Claims


Cardiac condition 15.0%

Cancer 11.2%



Pneumonia/respiratory infection 4.2%

Embolism 3.8%

Complication from surgery, treatment, procedure, medication 3.8%


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.

11b

severity of injUries resULting in deatH (closed claims with indemnity Payment)*


Percent of Closed


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

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

Embolism 7.0% $84,861

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.

22


The average indemnity payment by CNA on behalf of its nurse practitioner insureds is approximately $165,000.

Analysis of Closed Claims with the Highest Indemnity PaymentsThe 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 profes-

sional liability policies with limits of liability for indemnity payments of $1 mil-

lion 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 great-

er 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.

12a

anaLysis by severity (closed claims with indemnity Payment)

Indemnity Payment

Percent of Closed

Claims with Indemnity Payment*

Average Paid

Indemnity

Average Paid

Expense

Less than $250,000 74.6% $64,078 $45,815

$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.

23


12a

anaLysis by severity (closed claims with indemnity Payment)

Indemnity Payment

Percent of Closed

Claims with Indemnity Payment*

Average Paid

Indemnity

Average Paid

Expense

Less than $250,000 74.6% $64,078 $45,815

$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.

12bcLosed cLaims witH indemnity Payment of $500,000 or greater

Allegation InjuryPaid

Indemnity Specialty Location

Failure to diagnose and treat lung cancer Wrongful death $1,000,000 Family

medicine Clinic

Failure to diagnose endometrial cancer 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 delaysBrain injury $1,000,000 Pediatric/

neonatalEmergency

department

Incorrectly prescribed weight-loss medica-tion, 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 disabilityBrain injury $775,000 Adult/

geriatric

Hospital - inpatient services

Failure to diagnose bacterial endocarditis after several office visits

with recurrent complaintsParalysis $750,000 Adult/

geriatric Clinic

Incorrect diagnosis of bursitis, resulting in myocardial infarction and death

Wrongful death $650,000 Family

medicineFreestanding

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

medicineMedical

care office

Failure to obtain consultation following change in condition, resulting

in vegetative stateBrain 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-hospital-

based

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/

neonatalMedical

care office

24


risk management recommendationsThe following risk management recommendations, which reflect the preced-

ing 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.

InsuranceEnsure 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 PracticeAnnually 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.

DocumentationA complete health information record is the best legal defense. The follow-

ing 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

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 notrespond 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 medi-cation, 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.

26


concLUsionThe findings of this claims analysis confirm that nurse practitioners continue

to be vulnerable to professional liability claims. Despite tort reform meas-

ures and innovative legal defense strategies, nurse practitioner claim severity

remains high, with average indemnity and expense payments trending up-

ward 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 them-

selves 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.

27

What is the relationship between nurse practitioner liability claims and- level of professional

independence?- prescriptive authority?- educational setting?- experience with mentors?

29

H I G H L I G H T S F R O M T H E N S O 2 0 0 9 N U R S E P R A C T I T I O N E R S U R v E Y

HigHLigHts from tHe nso 2009 nUrse Practitioner sUrvey

introdUctionIn 2005, CNA and NSO released the Nurse Practitioner Claim Study, 1994–

2004. The study analyzed 10 years of claims brought against nurse practition-

ers (NPs) in the CNA HealthPro-NSO program. The study of the nurse prac-

titioner 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 practition-

ers on these and associated issues. The survey participants included nurse

practitioners who have participated in the NSO insurance program, compris-

ing those who have and who have not experienced claims. Key survey find-

ings 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.

30


sUrvey metHodoLogyKretschman 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 experi-

ence 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 sepa-

rately. Please note that registered nurses, certified registered nurse anesthe-

tists 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 partici-

pate, 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%

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 hav-

ing 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)

32


nso sUrvey excerPts

Demographics

Nursing Professional Type

Percent of Respondents

with Claims (Base = 287)


with No Claims

(Base = 2,750)

Total Percent

(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%

Gender




with No Claims

(Base = 2,742)

Total Percent

(Base = 2,977)

Male 14.5% 6.6% 7.2%

Female 85.5% 93.4% 92.8%

Total 100% 100% 100%

Age*




with No Claims

(Base = 2,742)

Total Percent

(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%

* Due to rounding, totals are slightly over or under 100 percent.

Total 100.1% 100.1% 99.9%

Highest Education Level Completed*




with No Claims

(Base = 2,742)

Total Percent

(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%

* Due to rounding, some totals are slightly under 100 percent.

Total 100% 99.9% 99.9%

Location of Practice




with No Claims

(Base = 2,728)

Total Percent

(Base = 2,961)

Rural 30.0% 21.6% 22.2%

Suburban 43.8% 40.9% 41.2%

Urban 26.2% 37.5% 36.6%

Total 100% 100% 100%

33


Nurse Practitioner Education/PreparationEighty-eight percent of all nurse respondents and 89 percent of claim respond-

ents stated that they used an on-site university program to achieve their nurse

practitioner designation. Only 5 percent of all nurse practitioners and 6 per-

cent 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.

Q2nUrse Practitioner edUcation/PreParation

How did you earn your NP designation?

Other (please specify)

None

On-line program

University/college on-site program

Hospital-based program

Community college program0%1%1%

1%2%

1%

89%88%88%

6%5%5%

0%0%0%

4%5%5%

■ Claim (Base=287)■ Non-claim (Base=2,750)■ Total (Base=3,037)

34


Clinical SpecialtyApproximately 50 percent of the nurse practitioners who completed the

survey are certified or licensed to work in family medicine. For most special-

ties, 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 propor-

tion of nurse practitioners with claims (3 percent versus 7 percent).

Q3nUrse Practitioner sPeciaLty

In what specialty area(s) are you certified or licensed as an NP? (Check all that apply.)


Women’s health (excludes obstetrics)

Behavioral health

Pediatrics

Occupational health

Oncology

Obstetrics/perinatal

Neonatal

Gerontology

Family medicine

Adult care22%

24%24%

59%49%50%

5%6%6%

0%1%1%

3%2%2%

0%1%1%

0%1%1%

3%7%7%

10%11%

13%

5%5%5%

7%9%9%


35


Clinical Hours Required in Nurse Practitioner ProgramsMore 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.

Q6nUrse Practitioner Program cLinicaL HoUrs reqUired

How many clinical hours were required in your NP program?


1,000 hours or more

800 to 999 hours

600 to 799 hours

400 to 599 hours

100 to 399 hours

Less than 100 hours

0 hours1%1%1%

3%3%3%

19%16%16%

26%26%26%

26%30%30%

4%8%

7%

16%13%13%

4%3%3%


mean nUmber of cLinicaL HoUrs reqUired in nUrse Practitioner Program

Average clinical hours required in NP program

Mean695 hours

631 hours636 hours


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.

36


Years as a Registered Nurse Prior to Becoming a Nurse PractitionerApproximately 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.

Q7nUmber 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?

More than 15 years

11 to 15 years

6 to 10 years

2 to 5 years

Less than 2 years4%

5%5%

18%19%19%

18%24%24%

20%16%16%

41%35%

36%


mean nUmber of HoUrs in Practice as a registered nUrse

Average years as an RN before becoming an NP

Mean13.9 years

12.9 years13.0 years


37


State Regulations Governing PracticeNurse practitioners’ scope of practice requirements vary by state, with most

states permitting nurse practitioners to function collaboratively with physi-

cians, 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 with-

out 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.

Q7nUmber 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?


Q8state regULations governing Practice

(At the time of the incident), state regulations governing my practice require(d): (Check one)


Direct physician supervision

Collaborative practice agreements

No physician oversight11%

15%15%

70%79%

78%

9%4%4%

10%3%3%


38


Years of Experience as a Nurse PractitionerSeventeen 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 bell-

shaped 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.

More years of experience as a nurse practitioner may minimize the risk of an incident.

Q13years Practicing as a nUrse Practitioner

(At the time of the incident), how many years have (had) you been an NP?

More than 15 years

11 to 15 years

6 to 10 years

2 to 5 years

Less than 2 years17%

12%12%

32%24%

25%

33%27%

28%

8%20%

19%

10%17%

16%


average nUmber of years as a nUrse Practitioner

Mean7.1 years

9.7 years9.5 years


39


Significance of a MentorNurse practitioners with claims were more likely than nurse practitioners with-

out 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 men-

tor 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).

Q13years Practicing as a nUrse Practitioner

(At the time of the incident), how many years have (had) you been an NP?


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?

No

Yes52%

37%39%

48%63%

61%


Q15ProfessionaL backgroUnd of mentor or coLLaborator

Who was the mentor or collaborator? (Check all that apply)


Clinical nurse specialist

Nurse practitioner

Physician87%

77%78%

30%51%

49%

3%7%7%

5%5%5%


40


Practicing Outside of CertificationNinety percent of nurse practitioners who have claims say they do not prac-

tice 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 pro-

portion 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 spe-

cialties is available on pages 63 and 64 of the complete study, which is avail-

able at www .nso .com/nPclaimstudy2009.

Q17Practicing oUtside of certification

(At the time of the incident), are (were) you practicing in a specialty area in which you were not certified?

No

Yes10%

16%16%

90%84%84%


41


Q18cLinicaL 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)


Women’s health (excludes obstetrics)

Behavioral health

Pediatrics

Oncology

Obstetrics/perinatal

Neonatal

Gerontology

Family medicine

Adult care13%

8%9%

13%9%9%

17%7%

8%

4%0%0%

4%1%1%

8%3%

4%

0%5%5%

13%10%10%

6%6%

0%

29%50%

49%

■ Claim (Base=24)■ Non-claim (Base=430)■ Total (Base=454)

42


Years Working in Specified Position at Time of IncidentAt 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.

Q19years working in tHis ParticULar Position

(At the time of the incident), how many years have (had) you worked in this particular position?

More than 15 years

11 to 15 years

6 to 10.9 years

4 to 5.9 years

2 to 3.9 years

Less than 2 years25%

30%30%

28%24%24%

16%13%13%

22%20%

21%

6%8%8%

3%4%4%


average years in Position Average years working in this particular position

Mean4.7 years

5.1 years5.1 years


43


Prescriptive AuthorityNurse 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 pre-

scribe Schedule II–v drugs (49 percent versus 60 percent) or Schedule III–v

drugs (21 percent versus 27 percent).

Q19years working in tHis ParticULar Position

(At the time of the incident), how many years have (had) you worked in this particular position?


Q20LeveL of PrescriPtive aUtHority

(At the time of the incident), what level of prescriptive authority do (did) you have? (Check all that apply)

None of the above

Schedule II-V

Schedule III-V

Schedule V

Non-scheduled prescription or legend drugs(e.g., prescription medications such as antibiotics)

32%36%36%

9%13%13%

21%27%

26%

49%60%

59%

13%6%6%


44


Daily Patient WorkloadPatient workload may contribute to malpractice exposure. Nurse practition-

ers 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 prac-

titioners 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.

Q22daiLy Patient workLoad

(At the time of the incident), what is (was) your average patient workload per day?

40 or more

30 to 39

25 to 29

20 to 24

15 to 19

10 to 14

Less than 10

0 (none)3%

2%2%

11%19%19%

16%24%24%

26%20%20%

23%19%19%

8%7%

8%

8%6%6%

4%2%2%


45


OvertimeThe large majority of nurse practitioners report that they were not required

to work overtime.

Q22daiLy Patient workLoad

(At the time of the incident), what is (was) your average patient workload per day?


average daiLy Patient workLoad(excluding nPs who do not see any patients)

Mean18.5 patients

16.2 patients 16.4 patients


average daiLy Patient workLoad

Mean19.0 patients

16.5 patients 16.7 patients


Q24overtime

(At the time of the incident, did) does your facility require you to work overtime?

No

Yes13%

17%17%

87%83%83%


46


Electronic Medical RecordsNurse practitioners who had claims were twice as likely to have utilized hand-

written medical records at the time of the incident than were nurse practi-

tioners without claims (72 percent versus 36 percent). They were also less

likely to have been using a combination of electronic and handwritten med-

ical records (16 percent versus 32 percent) at the time of the incident.

Seventy-two percent of nurse practitioners with claims reported using handwritten medical records

at their facility when the incident occurred.

Q27eLectronic medicaL records

(At the time of the incident, did) does your facility (Check one)


Utilize a combination of electronic andhandwritten medical records

Utilize handwritten medical records

Utilize electronic medical records8%

29%27%

72%36%

38%

16%32%

31%

4%4%4%


333 South Wabash, 26 SouthChicago, Illinois 606041.888.600.4776www .cna .com

159 East County Line RoadHatboro, PA 190401.800.247.1500www .nso .com

For additional information, please contact CNA HealthPro at 1-888-600-4776. 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 mate-

rial 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 with-

out notice. CNA policies are underwritten by the property/casualty companies of CNA, Chicago, IL.

CNA is a registered trademark of CNA Financial Corporation. ©2010 Continental Casualty Company. All rights reserved.

Printed 2/10.

Nurses Service Organization (NSO) is the nation’s largest administrator of professional liability insurance coverage to indi-

vidual nursing professionals. Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., an

affiliate of Aon Corporation. For more information about NSO, or to inquire about professional liability insurance for nurse

practitioners as well as nursing professionals, visit NSO on-line at www .nso .com or call 1-800-247-1500.

Date post:	13-Mar-2018
Category:	Documents
Upload:	vuongnhan
View:	213 times
Download:	1 times

Nurse practitioners are at the forefront of a paradigm ... practitioners are at the forefront ......

Documents