Liability of NP's

Editorial Team / Admin · Oct 13, 2007

Congratulations on your decision to become an NP.

If I were to become an NP, I would want to have a standard to follow in order to make perfect decisions about someone's care! My goal is to provide the best and safest care possible, and not get sued,

You should always practice within your SOP for your state NPA and adhere to the SOC for each and every disease entity/sitation as well as practice within the bounds of your NP education.

No one is perfect.

You have admirable goals.

I think you are on the right track.

Good luck.

Sunflower3 · Oct 13, 2007

Siri,

Thanks for your sage advice! So as long as I follow the standard each and every time to the letter, that my liability concerns should be diminished? I realize that no one is absolutely perfect, but I usually err on the side of caution, and am very conservative in my approach. And I fear making a mistake as an FNP! Has this topic been discussed before? When I graduated from nursing school the first time, I voiced this concern to my main instructor, who told me that since I was diligent to follow the rules, that I should be fine in practice, and I have been to this day, but it still concerns me. I just want to give my patients the very best, which is what they deserve! Any response is appreciated. UnitRN01

caldje · Oct 13, 2007

As an FNP you won't be alone. Always ask you supervising/colaborating physician if you have any doubt. If you still cannot figure out what to do, refer to the appropriate provider who has the knowledge and expertise to make the best decision for the patient. Be good to your patients, and they won't sue you. good luck, don't let the fear of being sued keep you from becoming a good provider.

Siri,
Thanks for your sage advice! So as long as I follow the standard each and every time to the letter, that my liability concerns should be diminished? I realize that no one is absolutely perfect, but I usually err on the side of caution, and am very conservative in my approach. And I fear making a mistake as an FNP! Has this topic been discussed before? When I graduated from nursing school the first time, I voiced this concern to my main instructor, who told me that since I was diligent to follow the rules, that I should be fine in practice, and I have been to this day, but it still concerns me. I just want to give my patients the very best, which is what they deserve! Any response is appreciated. UnitRN01

Editorial Team / Admin · Oct 14, 2007

Siri,
Thanks for your sage advice! So as long as I follow the standard each and every time to the letter, that my liability concerns should be diminished? I realize that no one is absolutely perfect, but I usually err on the side of caution, and am very conservative in my approach. And I fear making a mistake as an FNP! Has this topic been discussed before? When I graduated from nursing school the first time, I voiced this concern to my main instructor, who told me that since I was diligent to follow the rules, that I should be fine in practice, and I have been to this day, but it still concerns me. I just want to give my patients the very best, which is what they deserve! Any response is appreciated. UnitRN01

Anyone who is diligent to practice within their SOP and adhere to the SOC greatly diminishes their risk.

Sometimes exercising caution will carry you a long way. Sometimes you have to make an immediate decision; rapidly weighing the risks/benefits, (but still stay within standards of care), in order to treat the patient.

Every patient is an individual with the same disease process but treatment guilelines will vary from patient to patient based on a myriad of issues and/or presentations. It just takes experience. And, time.

And, as caldje said, you should have someone to whom you can bounce off ideas, voice your concerns, etc. And, you should ALWAYS know when to obtain a consult and know when to refer.

Don't allow your fears to overwhelm you. You will learn to turn the "fear" into the ability to be an astute diagnostician and thereby, provide the best possible care for your patient.

core0 · Oct 14, 2007

Hello NP's!
I'm seriously considering applying to either NP school or MSN in education. The liability issue leaves me wondering if the stress of being an NP is worth the effort. Do NP's function in their practice according to a standard of care algorithm? In other words, if you make clinical decisions based upon what you are taught in school, is the risk for making a mistake minimized? If I were to become an NP, I would want to have a standard to follow in order to make perfect decisions about someone's care! My goal is to provide the best and safest care possible, and not get sued, which I'm sure is everyone's goal! I'm basing my career decision on responses, so any and all responses are appreciated.
Thanks,
UnitRN01

I think you need to read up on standard of care. It is not an algorithm. The most common definition is how a similarly qualified practitioner would have managed the patients care under the same or similar circumstances. It usually only applies in court. So as an FNP you would be responsible for how an FNP would have treated the patient. However with the claim for independent practice you are essentially held to the same standard of care as a FP physician (correct me if I am wrong Siri). The standard of care also varies by specialty and by location. The local community standard of care may be quite different from positions laid out by national organization.

Education does not end when you leave school. Just as a physician continues to develop their knowledge base both after medical school and residency so too must any NPP. So you would not minimize mistakes by following just what you learn in school. Ideally you will have a mentor for the first year or two in practice where the greatest danger of mistakes are.

When you talk about standard of care algorithms what I am assuming you are really talking about is treatment algorithms. There are good algorithms developed for a variety of conditions. There are also good practice recommendations for a variety of conditions. You should definitely understand the latest practice guidelines for the conditions you follow. If you choose not to follow a practice guideline you should be able to elucidate a reason why you did not. For example in the case of strep throat if you use an algorithm instead of testing you should be able to show why you believe this to be better. The good thing about medicine is their is usually more than one way to skin a cat. You should also know the what the local community does. On the other hand if you say it is OK of your diabetics to run A1C's of 11 because it is mean to limit their sugar intake you will have a hard time justifying this if something goes wrong.

The use of algorithms is another piece that is debated. The use of algorithms is well established. However, knowing when to deviate from an algorithm or establishing your own method of practice is what differentiates a clinician from a technician. You will eventually develop your own practice style, but differentiating disease states and rapidly formulating a treatment plan is the hardest part of practicing medicine (or advance practice nursing). Eventually it becomes second nature, but it is a very difficult concept for some people.

A final comment on risk or getting sued. You stated that you goal is to provide the best and safest care possible, and not get sued. You also stated that you want to follow a standard to make perfect decisions about someone's care. This is an impossible standard.

Getting sued realistically has no relationship to the quality of care you provide. People who were appropriately treated will have bad outcomes and sue. People who were inappropriately treated will have bad outcomes and not sue. There are a number of studies that show the best predictor of not getting sued is your relationship with the patient.

As far as providing perfect care, as long as humans are involved as either patients or providers mistakes will happen. Patients will die. Bad outcomes will happen. The best you can do is have sufficient processes in place to minimize mistakes.

Practicing medicine is very difficult. One of my classmates, who was the best clinician in class, quit 2 months before graduation because he could not deal with the fact that he might be wrong and the patient would have a bad outcome. It is not for everyone, but it is very rewarding if you can stand the heat.

David Carpenter, PA-C

patrick1rn, MSN, RN, NP · Oct 20, 2007

:welcome:

I think you need to read up on standard of care. It is not an algorithm. The most common definition is how a similarly qualified practitioner would have managed the patients care under the same or similar circumstances. It usually only applies in court. So as an FNP you would be responsible for how an FNP would have treated the patient. However with the claim for independent practice you are essentially held to the same standard of care as a FP physician (correct me if I am wrong Siri). The standard of care also varies by specialty and by location. The local community standard of care may be quite different from positions laid out by national organization.
Education does not end when you leave school. Just as a physician continues to develop their knowledge base both after medical school and residency so too must any NPP. So you would not minimize mistakes by following just what you learn in school. Ideally you will have a mentor for the first year or two in practice where the greatest danger of mistakes are.
When you talk about standard of care algorithms what I am assuming you are really talking about is treatment algorithms. There are good algorithms developed for a variety of conditions. There are also good practice recommendations for a variety of conditions. You should definitely understand the latest practice guidelines for the conditions you follow. If you choose not to follow a practice guideline you should be able to elucidate a reason why you did not. For example in the case of strep throat if you use an algorithm instead of testing you should be able to show why you believe this to be better. The good thing about medicine is their is usually more than one way to skin a cat. You should also know the what the local community does. On the other hand if you say it is OK of your diabetics to run A1C's of 11 because it is mean to limit their sugar intake you will have a hard time justifying this if something goes wrong.
The use of algorithms is another piece that is debated. The use of algorithms is well established. However, knowing when to deviate from an algorithm or establishing your own method of practice is what differentiates a clinician from a technician. You will eventually develop your own practice style, but differentiating disease states and rapidly formulating a treatment plan is the hardest part of practicing medicine (or advance practice nursing). Eventually it becomes second nature, but it is a very difficult concept for some people.
A final comment on risk or getting sued. You stated that you goal is to provide the best and safest care possible, and not get sued. You also stated that you want to follow a standard to make perfect decisions about someone's care. This is an impossible standard.
Getting sued realistically has no relationship to the quality of care you provide. People who were appropriately treated will have bad outcomes and sue. People who were inappropriately treated will have bad outcomes and not sue. There are a number of studies that show the best predictor of not getting sued is your relationship with the patient.
As far as providing perfect care, as long as humans are involved as either patients or providers mistakes will happen. Patients will die. Bad outcomes will happen. The best you can do is have sufficient processes in place to minimize mistakes.
Practicing medicine is very difficult. One of my classmates, who was the best clinician in class, quit 2 months before graduation because he could not deal with the fact that he might be wrong and the patient would have a bad outcome. It is not for everyone, but it is very rewarding if you can stand the heat.
David Carpenter, PA-C

I am no expert by any means what so ever, but I am doing my clinical portion of my NP program and so far no algorithims. Do they have these in Medical assistant school , David ?

Editorial Team / Admin · Oct 20, 2007

:welcome:
I am no expert by any means what so ever, but I am doing my clinical portion of my NP program and so far no algorithims. Do they have these in Medical assistant school , David ?

Hello, patrick1rn,

David is a Physician Assistant, not a medical assistant. Hope this clears up any confusion.

caldje · Oct 20, 2007

:welcome:
I am no expert by any means what so ever, but I am doing my clinical portion of my NP program and so far no algorithims. Do they have these in Medical assistant school , David ?

for a good collection of algorithms you should look at the book "Ferri's clinical advisor 2008" it has a section full of algorithms that have been taken from various organizations. Im kind of surprised you haven't run into any algorithms since most large 'recommendations' articles include a few. For example, the ADA's new DM management guidelines include an algorithm on page S11. http://care.diabetesjournals.org/cgi/reprint/30/suppl_1/S4

The AAP's otitis media guidelines also include an algorithm on page 1460 & 1461. http://aappolicy.aappublications.org/cgi/reprint/pediatrics;113/5/1451.pdf

And the JNC 7 guidelines include an algorithm for the treatment of HTN on page 31. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

I love algorithms, especially when you are already very familiar with the subject the article is about and just want to get the nuts and bolts real quick to see if the recommendations are different from your current practices. I was also an EMT in a prior life, and got used to reading algorithms in that experience.