In addition to the longstanding issues of patients’ lack of access to health care and the increasing costs of that care, there continue to be concerns about the safety and quality of care being delivered in the United States. This is especially true as more information on the nature and extent of errors in health care has been brought to the forefront.
Since 1990, the National Practitioner Data Bank (NPDB) has been collecting information on health care practitioners, including NPs and PAs, with regard to disciplinary actions such as monetary judgments (both by settlement and jury decision), loss of licensure, and limitation of practice. Over the years, PAs and NPs have experienced increased liability (mostly as a result of their expanding scope of practice), greater patient care responsibilities, and more autonomy. However, according to an article in the March 20, 2000, edition of Medical Economics, “Judging from the actual number of malpractice cases settled, PAs and NPs are in court much less often than their doctor colleagues.”
Information from the NPDB, in fact, reveals that NPs and PAs still incur a remarkably low rate of malpractice judgments. Moreover, anecdotal data support the possibility that hiring a PA or NP may even reduce the risk of malpractice liability.
The Health Care Quality Improvement Act, passed by Congress in 1986, requires that all malpractice payments made on behalf of any clinician who is licensed, registered, or certified by the state must be reported to the NPDB. Since the data bank began collecting statistics, it has recorded a total of 235,797 paid claims for all physicians of every type, with an average paid claim (inflation adjusted) of $282,782. During that same period, the NPDB recorded a total of 1,130 paid claims for PAs, with an average paid claim of $86,568. The total number of NP claims was 470, but average claim data were not available.
You can get some perspective on these data by keeping in mind that in 2006, there were 633,000 physicians, 125,000 NPs, and 70,000 PAs practicing in the US. There are five physicians for every NP in the country; nine physicians for every PA. Can we surmise then that the number of physician-related paid claims should be five times that of NP-related paid claims and nine times that of PA-related claims?
In reality, the number of physician-related paid claims approaches 100 times that of PA-related paid claims. A further disparity is noted when mean losses are compared: The 2006 mean physician-related losses are 33% higher than PA-related losses ($312,000 for physicians vs $234,000 for PAs). Unfortunately, it should be noted that the mean rate for PAs is approaching that of the physician.
Another way of examining the differences among the malpractice experiences of NPs, PAs, and physicians is to calculate how many providers of each type exist for each malpractice paid claim. Data from 2006 show that one claim was paid for every 2.68 physicians, compared to one for every 210.43 NPs and one for every 619.5 PAs.
It is true that we don’t know for sure how accurate the data reported to the NPDB are. Variations in NP practice—whether independent, collaborative, or phys-ician-supervised—exist from state to state, which may affect the reliability of the data. Also, differences exist among states in the way NPs are licensed. In some states, an NP is licensed as a nurse while in others he or she would be licensed as an NP, which can similarly alter the reporting. And because prescriptive authority by PAs and NPs varies from state to state, it may be true that states are not on an equal footing when it comes to their settlement of claims against NPs or PAs.
Lastly, NPs are reported to the NPDB separately from certified nurse midwives (596 paid claims) and advanced practice nurses (1,181 claims including CRNAs). If they were reported as one group, that would also affect the numbers.
It must be remembered that each health care provider is responsible for his or her own negligent acts. Even if you are a dependent practitioner with a supervising physician who is responsible for your actions, that does not exonerate you from the risk of individual liability.
To win a negligence case and recover damages from an NP or PA, a patient must prove three things: that the PA or NP owed the patient a duty of care, that he or she breached that duty, and that the patient was harmed as a result of the NP’s or PA’s action or failure to act. Conduct that may lead to liability includes failure to properly diagnose, failure to refer, exceeding one’s scope of practice, negligent monitoring, failure to question a physician’s abnormal order, or failure to properly follow up.
In most cases, PAs and NPs are covered under their employer’s policy. In spite of that, they may still be liable for their own negligence and for all or part of a plaintiff’s award or settlement. It is important, in my experience, that NPs and PAs maintain their own personal medical liability insurance.
There are plenty of articles and handbooks that discuss methods to avoid medical liability, such as the Physician Assistant Legal Handbook by Aspen Health Law and Compliance Center and The Advanced Practice Nurse’s Legal Handbook by Rebecca F. Cady, RNC, BSN, JD. But in my opinion, they all boil down to the following basic principles:
• Know and understand your scope of practice under state law.
• Know and understand your hospital or institutional policies.
• Know and understand the importance of communicating honestly with your patients and your supervising or collaborating physician.
Ensuring patient safety and improving quality of care are steadfast goals for all NPs and PAs. We need to continue our discussions on best practices for preventing medical errors as well as finding ways to remove barriers to effective practice. I would love to hear from you about these matters. Please e-mail me at PAeditor@qhc.com.