Rising nurse claims

MPS has seen a steady rise in the number of claims involving practice nurses, with ‘delay in diagnosis’ being the most common type of claim. Kate Taylor, Clinical Risk Manager, MPS Educational Services, reveals more

Understanding the common claims facing nurses can help nurses to ensure that they employ risk management strategies and efforts to reduce risks.

A study of general practice claims opened by MPS over the period 2007 to 2011, where practice nurses/nurse practitioners were involved in the care of patients, identifies that 33% of cases related to a delay in diagnosis. Further analysis of these claims identifies that nurses are seeing patients with more acute presentations, who perhaps historically would have been seen by a GP. Many of these claims involved nurses not referring the patients’ care onwards either to a medical colleague or a specialist healthcare professional.

Common claims

While missed diagnosis was the most common, the penultimate most common claim was chronic disease management, with 16% of claims during the four-year period relating to this. Chronic diseases include diabetes, asthma, coronary heart disease and hypertension. Chronic disease management is a huge part of the nursing role within general practice, so the risk it presents needs to be tackled.

Key contributing factors include:

• Failure/delay to refer patient to GP/specialist
• Inadequate assessment of the patient’s condition
• Inadequate monitoring of the disease progression.

At a glance

• Claims against nurses in general practice are on the up
• ‘Delay in diagnosis’ is the most common reason for claiming against nurses
• Understanding the common pitfalls and employing risk management strategies will reduce the risk of such claims
• Practices should ensure that appropriate practice protocols are in place and that appropriate indemnity arrangements have been made.

The study shows that 9% of claims involving nurses working in general practice relate to issues associated with immunisations, be it childhood immunisations, flu vaccinations or travel vaccinations.

Key contributing factors include:

• Administration of the correct drug/dose
• Method of administration including technique
• Schedule of vaccinations, ie, travel vaccinations.

Why are nurse claims increasing?

The role of nurses working within general practice is ever-changing, with an expectation that they take on additional responsibilities and increased autonomy; ranging from chronic disease management clinics, nurse triage, family planning, and immunisation clinics alongside the introduction of the advanced nurse practitioner role, healthcare assistant and nurse prescribing. With this expansion of the nursing role comes the increased risk of clinical negligence claims from patients.

Across all providers healthcare litigation is increasing with patients being more aware of their rights, and MPS remains concerned that as nurses’ autonomy increases so does the risk of litigation. The Nursing and Midwifery Council Code of Conduct (2008) states that nurses must recognise and work within the limits of their competence; therefore it is imperative that nurses ensure that they have received the appropriate training and skills to undertake their role.1

Top risk management tips

• Practice clinical guidelines/protocols should be in place for:
  • chronic disease management
  • family planning
  • immunisations
  • wound care
  • ear syringing
  • minor surgery.
• Nurses should be supported in maintaining and developing their clinical skills and knowledge. 
• Ensure nurses maintain complete contemporaneous records of all patient consultations. 
• Provide access to an appropriate level of support and mentorship for nurses.
• Ensure nurses working within general practice have suitable indemnity arrangements in place. 
• Nurses undertaking extended roles must consider the need to gain appropriate consent, particularly in relation to childhood immunisations and minor surgical procedures.

Common claims against nurses in general practice

*Includes: infection control, medical records, phlebotomy, joint injections

NB, this information is based on MPS claims for the period 2007-2011.

Risks of nurse triage

Nursing roles are increasingly being developed to undertake triage of appointments; this way of prioritising patients helps to identify the patient’s problems and directs them to the most appropriate care pathway, eg, urgent appointment, routine appointment, telephone consultation, and self help.

Nurse triage tends to be provided over the telephone and should be supported by practice guidelines/protocols. Nurse triage is also not without risk; MPS claims data identifies a number of cases whereby assessment of the patient’s needs has been inadequate, resulting in an adverse outcome. Nurses undertaking triage need to be supported by guidelines and protocols and ensure that they work within their own sphere of competency.

 

Nurse triage tends to be provided over the telephone and should be supported by practice guidelines/protocols

It is also vital that the reception staff who are responsible for referring patients for nurse triage are supported with guidelines; this will help to reduce the risk of nurses seeing patients inappropriately and will also ensure that the patient sees the most appropriate clinician.

Typical scenarios

Case 1
A patient with type 1 diabetes was seen by a practice nurse with cellulitis of his right foot. The practice nurse failed to refer the patient to the GP/specialist and the patient subsequently required a below knee amputation.

Case 2
Child A presented at the immunisation clinic together with their grandmother. The practice nurse administered an MMR booster without parental consent. The child did not suffer any physical harm, but the child’s parents experienced distress and anxiety.

Advanced nurse practitioners

 

Advanced nursing roles are increasing; nurses working within these advanced roles must also recognise their own limits

In recent years within general practice there has been a random use of titles by nurses that infer levels of clinical expertise that could not be verified; the subsequent development of the advanced nurse practitioner course has helped to overcome this and has added an additional layer of monitoring of appropriate competency, education and tangible evidence-based practice (RCN 2012).2In MPS experience, advanced nursing roles are increasing; nurses working within these advanced roles must also recognise their own limits.

Conclusion

In conclusion, increasingly nurses are at risk of clinical negligence claims from patients; however, understanding the common pitfalls and employing appropriate risk management strategies will reduce the risk of such claims. It is also essential that practices ensure that they have appropriate indemnity arrangements in place for all employed staff.

References

1. NMC, Code of Professional Conduct, London (2008)
2. RCN, Advanced Nurse Practitioners: An RCN Guide to Advanced Nursing Practice (2012)