Medical Malpractice Lawsuits Involving Nonphysician Providers in the Emergency Department

Emergency medicine (EM) increasingly relies on non-physician providers (NPPs), including nurse practitioners (NPs) and physician assistants (PAs). The objective of this study is to provide a narrative review of NPP involvement in medical malpractice lawsuits within EM.

Within the Jury Verdicts and Settlements database of Westlaw, we searched for cases occurring from 1980 to 2023 with the term "malpractice," and either: "physician assistant" or "nurse practitioner," which yielded 1,043 cases. After excluding duplicates, cases without relevant NPP involvement, expert-witness cases, non-NP nursing cases, and those lacking sufficient clinical detail, 670 cases remained, of which 144 involved EM. Two abstractors collected data in duplicate with discrepancies resolved by discussion, summarizing categorical variables as frequencies and percentages and continuous variables as means or medians as appropriate.

Cases represented 32 states, most occurring between 2001-2015, with patients having a median age of 36 years. Physicians were named in 77.7% of cases, though, only saw the patient in 40.5% of cases. The most common diagnoses were infectious and neurologic conditions (each 14.6%), and misdiagnosis was the leading error, present in 88.2% of cases, with missed treatment (92% vs. 55%; 95% CI 1.67 (1.30, 2.14), p < 0.001) and communication errors (70% vs 40%; 95% CI 1.76. (1.21, 2.55), p=0.004) significantly more common when no physician was involved. Patient outcomes were severe with 34% of cases resulting in death and 48.6% in permanent disability. Most lawsuits resulted in no liability (57.6%). Plaintiff verdicts and settlements averaged more than $1.3 million.

This review highlights types of situations in which NPP involvement in EM led to a lawsuit. Physicians were named in the majority of lawsuits, while only directly evaluating the patients in less than half of cases. Clear supervisory standards for physicians overseeing NPPs are needed to improve patient safety and limit malpractice risk for both physicians an NPPs.