The roles and responsibilities of registered nurses continues to increase as more nurses attain Bachelor of Science in Nursing (BSN) and nursing doctoral degrees (Buerhaus, Auerbach, & Staiger, 2016). Today, registered nurses monitor critical physiological data (Stewart, Carman, Spegman, & Sabol, 2014), manage sophisticated lifesaving equipment (Boling, Dennis, Tribble, Rajagopalan, & Hoopes, 2016), organize the delivery of countless patient services (Lovett, Illg, & Sweeney, 2014), and successfully manage healthcare community clinics (Randall, Crawford, Currie, River, & Betihavas, 2017). As a result, registered nurses have more autonomy and professional accountability than ever before. Indeed, with this role expansion, staff nurses, nursing faculty, and nursing administrators must be cognizant of the fact that nurses are now more exposed to civil malpractice claims than at any other time in the history of nursing.
Several articles have reported on diagnosis-related malpractice claims (Brock, Nicholson, & Hooker, 2017; Jordan, 2015; Lovett et al., 2014; Mccool, Guidera, Griffinger, & Sacan, 2015; Saber Tehrani et al., 2013), all of which report malpractice claims naming physicians, physician assistants, nurse practitioners, nurse midwives, or certified registered nurse anesthetists. Limited medico-legal data is available on monitoring-related cases that name staff nurses as the primary responsible service in malpractice cases. The purpose of this study is to identify the most common contributing factors of malpractice claims naming staff nurses, the level of harm associated with these factors, and the financial expense that results.
Methods
We conducted a retrospective analysis of the Controlled Risk Insurance Company (CRICO) Strategies’ repository of malpractice claims, which includes approximately 30% of all malpractice claims made in the United States. This review, which included monitoring claims made between 2007 and 2016, determined that nursing was named as the primary responsible service in 907 closed monitoring-related cases.
A team of registered nurses trained as taxonomy specialists coded all cases in the CRICO repository of malpractice claims. The coding process includes assigning contributing factors to the cases and the level of severity was rated according to the National Association of Insurance Commissioners Severity Scale. The coding process includes systematic auditing by a governance committee consisting of physicians, attorneys, and other risk management specialists.
We determined summary statistics for the contributing factors of each case type, the level of patient harm, and the financial expense. We then conducted ordinal logistic regression using the level of patient harm as the dependent variable and contributing factors as the independent variables. We additionally conducted linear regression using indemnity incurred as the dependent variable and contributing factors as the independent variables.
Results
This review determined that nursing was named as the primary responsible service in 907 closed monitoring-related cases. The median age range for all claimants was between 60 and 69 years of age and 54.8% of all claimants were female. Most adverse events occurred in the inpatient setting (90.1%), while the remaining events occurred in the ambulatory setting (5.73%) or the emergency department (3.53%). The location of the event was not known in six claims (0.66%). The most common contributing factor, by far, was patient monitoring (n=751; 82.8%), followed by insufficient documentation (n=349; 38.48%). Higher odds of death was significantly associated with communication among providers (OR: 2.27, 95%CI: 1.60, 3.21), inadequate staffing (OR: 2.80, 95%CI: 1.05, 7.42), clinical environment busyness (OR: 7.5, 95%CI: 2.47, 22.80), working weekend, nightshift, or holiday (OR: 2.42, 95%CI: 1.53, 3.83), and supervision (OR: 1.88, 95%CI: 1.00, 3.53). Higher indemnity incurred was significantly associated with training and education (p = 0.025), failure to follow policy (p < 0.001), communication among providers (p = 0.016), inadequate staffing (p < 0.001), and supervision (p < 0.001).
Conclusions
As the nursing profession continues to become increasingly integral in healthcare and care delivery, we succeed to greater exposure and, by extension, greater risk to being litigated in a malpractice lawsuit. Increased awareness of monitoring-related cases naming nurses will allow for tailored nursing education and training to help improve quality and patient safety, while reducing the number of preventable adverse events and malpractice cases naming staff nurses.
The authors thank CRICO/Risk Management
Foundation of the Harvard Medical Institution