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July 2022

Nurse practitioners face multiple jeopardy for a single incident





A review of nurse practitioner cases notified to leading medical defence organisation, the Medical Defence Union (MDU), has found nurses now face a similar range of medico-legal investigations into incidents as doctors.

Between 2017 and 2021, the MDU helped 400 nurse members with medicolegal processes including complaints, claims, disciplinary procedures and NMC investigations. The MDU found it is common for a number of different investigations to be launched into a single incident, known as multiple jeopardy.

The number of cases notified remained steady overall compared with a previous five-year period. This is despite claims arising from primary care incidents after 1 April 2019 not being included in the figures as they are now dealt with by NHS Resolution. 

MDU medico-legal adviser Dr Ellie Mein said: ‘As NHS services seek to recover from pandemic disruption, nurse practitioners are increasingly taking on expanded roles and are critical to the recovery.  

‘Multiple jeopardy is common among the types of cases we see. Investigations into a single clinical incident involving nurse members can include patient complaints, disciplinary inquiries, NMC investigations, inquests/fatal accident enquiries, claims for negligence and even criminal investigations.

‘It is important to realise that state back indemnity schemes only cover clinical negligence claims.’

Reasons given for complaints (in descending order)

1. Wrong or delayed diagnosis. Cancer was the most common missed condition, closely followed by a serious infection, then fractures.

2. Communication failure or 'poor attitude'. This issue could be seen in isolation or as part of a wider complaint. It was cited as an issue in several NMC investigations.

3. Delayed referrals or investigations.

4. Prescribing errors - many of these being vaccine-related.

5. Complications following procedures such as suture removal, phlebotomy, cervical smears and injections.

6. Contraceptive advice or treatment complications.

7. Inadequate wound care, especially in patients with diabetes or patients who were bed-bound.

The MDU has also published advice on its website to help nurses avoid a complaint.

Refer patients to a medical colleague if the diagnosis is unclear

With the prevalence of complaints against nurse practitioners alleging wrong or delayed diagnosis, careful history-taking and examination is essential in reaching an accurate diagnosis.

Communicate clearly with patients

Numerous complaints were directly about poor communication, or a perceived uncaring attitude of the nurse practitioner. Many more cases included alleged 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 timeframe the patient should seek further medical care. (See Safety netting: why we must all do it)

Keep up to date and ensure you work within your level of competence

Clinical errors including prescribing errors are easily made and relatively common. Ensure you are aware of and follow local and national guidelines as well as practice policies and procedures.

If unsure, seek advice from your colleagues or refer for further investigation or treatment.

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. Take special care if communicating by email with patients, ensuring you follow practice policy.

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 regardless of whether the patient and nurse are the same or different genders. This is in line with local and national guidance; record full details of your discussions in the notes.

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 phone.

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 your indemnity provider 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 assistance if they find themselves facing a complaint or claim.

Medical Defence Union. Minimising complaints risk for nurse practitioners. https://www.themdu.com/guidance-and-advice/guides/minimising-complaints-risk-for-nurse-practitioners

Practice Nurse 2022;52(6): online only