Fitzgerald Health Education Associates (FHEA) is committed to the success of nurse practitioners; we publish practical information for practicing NPs and NP students, which includes NP interviews, NP certification Q&A;, avoiding malpractice, and news.
Issue link: https://fhea.epubxp.com/i/372490
10 fhea.com Fitzgerald Health Education Associates, Inc., August 2014 NP Firsts Avoiding Malpractice: A Case Analysis Case A 48-year-old woman with a 20-pack-year history of smoking slipped and fell in the shower on a holiday weekend. She went to the emergency department, where x-rays were taken. The radiologist observed several old rib fractures, several new rib fractures, and an infiltrate in the right upper lobe of the lung. He recommended follow-up of the infiltrate. The patient was told to see her healthcare provider. The patient visited her primary care nurse practitioner the follow- ing week. The NP treated her for pneumonia and or- dered a repeat chest x-ray in 2 weeks. The patient complied. A radiologist read the second x-ray as "al- most clear" and made no further recommendations. At this point the NP began to address other issues with the patient. The NP evaluated her for alcohol abuse and domestic violence, and addressed health- screening issues such as mammography. Liver func- tion tests were found to be abnormal. The NP noted her efforts trying to get the patient to see a gastroen- terologist for follow-up of the abnormal liver function tests. The NP said she also told the patient to get a re- peat chest x-ray. The patient did not comply. Nine months later the patient returned with hemoptysis and shoulder pain. An x-ray showed extensive carci- noma of the right lung. The patient died about 6 months later. The family sued the NP for failure to diagnose lung cancer. The NP stated that she had told the patient to get a third x-ray but that the patient was noncompliant. There was no clear notation in the patient's record that described the NP's efforts to have the patient get a third x-ray. There was an illegi- ble notation, which may have said "x-ray." The case was settled for an unknown amount.* Standard of Care In a deposition before the trial, the plaintiff 's expert witness, an internist, testified that the standard of care for follow-up in this case would include all of the following: 1. A frank discussion with the patient about the gravi- ty of the problem, with the clinician telling the pa- tient clearly, "You could die if we don't get to the bottom of this x-ray abnormality" (referring to the "almost clear" second x-ray). "'Almost clear' is not good enough, especially in a smoker," the witness testified. 2. If no follow-up x-ray is documented in 2 weeks, a telephone call must be made to the patient, ex- plaining once again the necessity of getting follow- up, citing an urgent timeframe. 3. If no follow-up is documented in 2 weeks, the clini- cian must send a certified letter, restating what the patient should do, the timeframe, and the risks of noncompliance. The expert testified that if the NP had a receipt prov- ing that a certified letter was delivered, with a copy of the letter in the chart, the NP would have met the standard of care for follow-up of an abnormal x-ray. Here are two definitions of "standard of care": • A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. • There is no medical definition for standard of care, but the term is established in law. 1 In legal terms, standard of care is the level at which the average, prudent provider in a given community would practice. It is how similarly qualified practitioners Protecting Yourself When the Patient Is Noncompliant: Standard of Care for Follow-up Carolyn Buppert, NP, JD