Nurse Practitioners and Medical Malpractice

Case Study:
Failure to timely diagnose brain tumor;
Failure to obtain physician consultation;
Failure to facilitate timely referral to neurologist

Settlement Payment: $500,000 Legal Expenses: $5,892

Note: There were multiple co-defendants in this claim who are not discussed in this scenario. Monetary amounts represent only the payments made on behalf of the nurse practitioner. Any amounts paid on behalf of the co-defendants are not available. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the nurse practitioner.

The pediatric nurse practitioner (defendant) was employed by a pediatrician to render care and treatment to patients in his private office practice.

The infant patient (plaintiff) was born with no complications twenty-one days prior to his first well-baby examination by the defendant’s physician employer (co-defendant). The codefendant identified mild jaundice and a possible diagnosis of failure to thrive. The patient did not return until age 6 months when the defendant nurse practitioner examined him for the first time. She documented that the patient was developing normally. The patient’s mother missed the next two well baby appointments, and office personnel called to remind the mother to schedule a well baby check. During the telephone conversation, the mother reported the patient sometimes appeared cross-eyed. The defendant nurse practitioner reassured the mother that this can be normal in infants and scheduled an appointment for one week later. The patient’s mother did not keep the appointment.

Six weeks later, when the patient was 10 months old, the defendant nurse practitioner examined him for the second time. She identified developmental delays, including the patient’s inability to sit or crawl, and observed and documented periodic crossing of the infant’s eyes. The defendant nurse practitioner consulted with the co-defendant, and they agreed to refer the patient to a pediatric neurodevelopmental clinic. Eleven days later, the defendant nurse practitioner wrote to the clinic requesting a copy of their findings following its evaluation of the patient. The defendant nurse practitioner subsequently sent a copy of the patient’s medical records to the clinic.

At age 11 months, the defendant nurse practitioner examined the patient. The mother indicated she had not yet been contacted for an appointment by the neurodevelopmental clinic. Developmental delays (absence of sitting, crawling and/or rolling over) persisted. The defendant nurse practitioner next saw the patient for the 12 month checkup and found him to have marked developmental delays with minimal muscle tone, absent social interaction and absent smile. Two weeks later (approximately 2 months following the initial referral from the defendant nurse practitioner), the neurodevelopmental clinic performed CT and MRI scans revealing right choroid plexus papilloma. Five days later, the patient underwent craniotomy and resection of the papilloma. The prognosis was guarded, but the surgeon was hopeful the patient would recover without permanent neurological damage.

Subsequent neurological examination of the patient at age 7 found him to be mildly retarded (IQ of 66). The consultant reported that the patient will likely require lifelong assistance, and it is unlikely that the patient will be able to live independently as an adult.

Resolution

The tumor was benign but experts believed the failure to obtain evaluation on an urgent basis resulted in prolonged increasing intracranial pressure that was a causative factor of the patient’s permanent neurological problems.

Experts were critical of the defendant nurse practitioner’s failure to appreciate the severity of the patient’s condition and determined that the defendant nurse practitioner should have facilitated neurological evaluation of the patient on an urgent basis.

Given the need for lifelong assistance, the policy limits were tendered. The primary insurer managed the ongoing investigation and defense of the matter, and the case was subsequently settled.

Risk Management Comments

Despite the mother’s concern that the neurodevelopmental clinic was slow in providing an appointment and despite the presence of increasing neurological symptoms, the defendant nurse practitioner did not facilitate obtaining an urgent referral, nor did she obtain diagnostic tests independently or take actions to refer the patient to an alternative neurological specialist or clinic.

Risk Management Recommendations

• Practice within the established standard of care and obtain the appropriate objective diagnostic tests and consultations to identify the cause for unusual or abnormal findings.
• Comply with facility policy requiring physician supervision regardless of whether such supervision is required under the state scope of practice.
• Perform indicated diagnostic tests when abnormal or unusual symptoms are observed. The results of such tests may identify the need for medically urgent intervention.
• Facilitate referrals on an urgent basis, where indicated, and refer the patient to an alternative provider if there are delays in obtaining necessary consultation and/or testing.
• Investigate parental concerns that may be signs of an underlying illness or disease process, especially when objective clinical signs are present upon examination.