During 2015, there were 25 new clinical negligence claims brought against nurse practitioner members, compared to just two claims 10 years earlier. Similarly, cases relating to patient complaints against nurse practitioners rose from four 10 years ago, to over 40 in the last 12 months. While the numbers are relatively small compared to those involving GPs, this represents a significant increase in both complaints and claims against nurse practitioners.
Dealing with negligence claims can be costly. In one claim settled by the MDU on behalf of a nurse practitioner member, compensation of more than £2 million was paid to a patient who suffered a stroke after being prescribed a contraceptive.
Reasons for complaints
The top five reasons for complaints and claims against MDU nurse practitioner members over the last five years were:
- Wrong or delayed diagnosis which was the main issue in 30% of complaints and 40% of claims.
- Communication failure or 'poor attitude' was the second most common concern, causing 16% of complaints.
- Delayed referrals lay behind 9% of complaints and 14% of claims
- Prescribing errors accounted for 8% of complaints and 12% of claims
- Complications following procedures such as ear syringing, cryotherapy, suture removal, phlebotomy, cervical smears and injections accounted for 13% of claims.
- Contraceptive advice or treatment complications also accounted for 7% of claims and 9% of complaints.
While it's inevitable that most nurse practitioners will face a complaint at some point in their career, there are steps you can take to minimise the risk.
Refer patients to a medical colleague if the diagnosis is unclear
With around a third of complaints and claims against nurse practitioners alleging wrong or delayed diagnosis, careful history taking and examination is essential in reaching an accurate diagnosis.
Clearly communicate with patients
16% of complaints were directly about poor communication, or a perceived uncaring attitude of the nurse practitioner and many more cases included peripheral communication failings. Always take care to explain what you are doing and why, and check the patient has understood.
Take particular care when providing safety netting advice such as under what circumstances and time frame the patient should seek further medical care.
Keep up to date and ensure you work within your level of competence
Clinical errors including prescribing errors are easily made and reasonably common, accounting for around 10% of cases we see. Ensure you are aware of and follow local and national guidelines, and practice policies and procedures.
If unsure, seek advice from your colleagues or refer for further investigation or treatment. 14% of claims related to a failure to refer on.
Respect patient confidentiality
Confidentiality is easily breached inadvertently. Don't discuss patients where you might be overheard, or leave written records where they might be seen. Do not assume that a competent child or adult would be happy to share information with a close family member or spouse. Avoid leaving messages on answer machines or voicemail unless you have specific consent from the patient to do so.
Don't share information about patients on social media, even if the details seem to be unidentifiable, and take special care if communicating by email with patients, ensuring you follow practice policy with regard to this.
Get informed consent
Always ensure you explain fully what you intend to do before examining a patient, prescribing, performing a procedure, or referring. Tell patients about the risks, benefits and alternative options open to them, including the option of doing nothing, so that the patient can make an informed choice.
Offer a chaperone for intimate examinations, in line with local and national guidance, and record in the notes full details of your discussions.
Keep detailed records
Accurate and detailed records are essential for good clinical care, but they are also vital when responding to a complaint or claim. Make sure you keep a record of all your discussions with patients including those over the telephone.
Include negative as well as positive findings such as an absence of fever or neck stiffness. You have an ethical and legal responsibility to ensure the records are detailed and accurate.
Check your indemnity
It's important to take individual responsibility for your own indemnity and ensure you keep the MDU up to date with the type of work you are doing. This is in line with the NMC requirement to have 'an appropriate indemnity arrangement in place relevant to your scope of practice'.
Doing so will give nurses in more advanced roles the peace of mind to know they can ask for our assistance if they find themselves facing a complaint or claim.
What to do if something goes wrong
If you become aware of a potential problem, the MDU advises:
- Be open and honest. Apologise to the patient where appropriate and explain what has happened, and what can be done to rectify things.
- Document carefully in the records what has happened, and what you have explained to the patient.
- Log any incident in accordance with your employer's policies, which should comply with the statutory duty of candour.
- Reflect carefully on what has happened and see what you can learn, for example by discussing with a colleague. Document your reflections and any additional learning or CPD you do as a result in your appraisal folder, and discuss at your next appraisal. NHS England has devised an 'e-form' for general practice staff to submit patient safety incident reports to the National Reporting and Learning System (NRLS), the NHS national patient safety incident database.
- Take an active part in dealing with any complaints process.
- If you are unsure what to do or need advice, contact your medical defence organisation.