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Review

Nurse Professional Liability Exposures: 2015 Claim Report Update

to understand some of the most common legal allegations. As you read, think about ways to mitigate the risks listed in the report.

Respond to the following in a minimum of 500 words:

What struck you most about the report or the allegations discussed?

Select 1 example or illustration from 1 of the claims categories and explain what could have been done to mitigate the risk that led to the claim.

Nurse Professional
Liability Exposures:
2015 Claim Report Update
A COMPARATIVE ANALYSIS FROM
CNA AND NURSES SERVICE ORGANIZATION
PART 1 Nurse Professional Liability Exposures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Database and Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Analysis of claims by licensure type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Analysis of severity by year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Nurse closed claims with expense payments only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Analysis of severity by nurse specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Analysis of severity by location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Analysis of Severity by Allegation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Allegation by category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Analysis of Allegation Sub-categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Allegations related to assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Allegations related to monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Allegations related to treatment and care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Claim Scenario: Delay in Implementing Provider Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Allegations related to medication administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Claim Scenario: Medication Error Resulting in Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Allegations related to patients’ rights, patient abuse and professional conduct . . . . . . . . . . . . . 28
Analysis of Severity by Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Analysis of fatal injuries by underlying cause of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Analysis of severity by cause of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Analysis of obstetrics-related injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Analysis of severity by disability outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analysis of director of nursing (DON) closed claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Claims related to agency nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Claim Scenario: Successful Defense of a Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Licensed practical/licensed vocational nurse closed claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Summary of Closed Claims with a Minimum Indemnity Payment of $1 Million . . . . . . . . . . . . . . . . . . . 39
Risk Control Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Patient safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Assessment and monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Treatment and care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Chain of command . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Scope of practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Risk Control Self-assessment Checklist for Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Claim Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Everyday practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Once you become aware of a claim or potential claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
PART 2 Nurses Service Organization’s
Analysis of License Protection Paid Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
License Defense Paid Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis of claims by licensure type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis of claims by location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Analysis of claims by allegation class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Average payment by allegation class . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Claims by Allegation Class Sub-Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Allegations related to sub-category of professional conduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Allegations related to sub-category of patients’ rights and patient abuse . . . . . . . . . . . . . . . . . . . 54
Allegations related to sub-category of improper treatment and care . . . . . . . . . . . . . . . . . . . . . . . 55
Allegations related to sub-category of medication administration . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Licensing Board Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Comparison of 2011 and 2015 distribution of licensing board actions . . . . . . . . . . . . . . . . . . . . . . . 57
Explanation of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
General Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
PART 3 Highlights from Nurses Service Organization’s
2015 Qualitative Nurse Work Profile Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Topic 1: Respondent Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Nursing licensure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Pre-licensure nursing program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Origin of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Additional certifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Years in practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Topic 2: Current Practice Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Technology and rapid access to information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Technology and patient records access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Managing technology and time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Technology and information verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Usage of electronic patient notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Access to evidence-based data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Staff development opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Employment practice periodic checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Topic 3: About the Claim Submitted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Working situation at the time of the incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Employment status at the time of the incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Years in practice at the time of the incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Magnetâ„¢ designation at the time of the incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Substance abuse procedure in place at the time of the incident . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Tenure in position at the time of the incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Topic 4: About the Facility Where the Incident Occurred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Technology in the workplace at the time of the incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
How long were you using technology at the time of the incident? . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Perceived patient benefit of technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Rapid response team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
PART 1 Nurse Professional Liability Exposures
CNA Five-year Closed Claims Analysis
(January 1, 2010-December 31, 2014)
and Risk Control Self-assessment for Nurses
Introduction
For over 30 years, CNA and our business partners at Nurses Service Organization (NSO) have been
committed to helping nurses insure themselves against loss by providing specialized insurance
coverage and working to enhance their risk awareness. Our joint professional program is the nation’s
largest underwriter of professional liability insurance for individual nursing professionals, with more
than 550,000 policies in force. CNA/NSO-insured nurses provide healthcare in an increasingly
broad array of locations and specialties, including hospitals, aging services facilities, outpatient and
ambulatory centers, practitioner offices, schools, community and retail health settings, spas and
aesthetic/cosmetic centers.
Purpose
In collaboration with NSO, we are pleased to present our third report on nurses’ risk exposures,
which examines CNA nurse claims that closed between January 1, 2010 and December 31, 2014.
Our goal is to identify liability patterns and trends in order to help nurses understand their areas of
greatest vulnerability, in order to take appropriate action to protect patients from harm and reduce
the risk of potential litigation.
When possible, this report compares CNA/NSO nurse professional liability closed claims that occurred
between January 1, 2006 and December 31, 2010 with the corresponding set of closed claims dating
from January 1, 2010 through December 31, 2014. The two groups of closed claims are referred to
as the 2011 and 2015 closed claim reports, respectively. This comparison provides a broader historical
perspective on claim characteristics, including trends in exposures and severity.
The report also summarizes individual claims with settlements or judgment awards equal to or
greater than $1 million. Detailed case studies illustrate failure to comply with professional standards
of care, resulting in patient injury and consequent claims of negligence. Finally, risk control recommendations and a self-assessment checklist are included to assist nurses in reviewing their custom
and practice in relation to the risks identified in the report.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
6
Database and Methodology
The report includes only those CNA professional liability closed claims that:
– Involved a registered nurse (RN), licensed practical nurse (LPN) .
or licensed vocational nurse (LVN).
– Closed between January 1, 2010 and December 31, 2014 .
(although they may have been reported earlier).
– Resulted in an indemnity payment of $10,000 or greater.
These inclusion criteria were applied to 10,639 reported adverse incidents and claims that closed
during the designated time period. The final primary database comprises 549 nurse closed claims,
which were subsequently reviewed and analyzed.
In addition to the primary dataset of claims that closed from January 1, 2010 to December 31, 2014 (the
2015 dataset), a dataset consisting of claims that closed between January 1, 2006 and December 31,
2010 (the 2011 dataset) was utilized in this report to draw comparisons and identify trends. Since
both of these datasets include closed claims from 2010, it is important to note that the two datasets
are not fully independent. Nevertheless, by comparing the two datasets we can see how the average
paid indemnity amounts associated with various claim characteristics are changing over time and
better identify patterns in nurse claim activity and litigation. The 2011 dataset includes 516 professional
liability claims, while the 2015 dataset includes 549 professional liability claims.
As this report has unique data inclusion criteria, readers should exercise caution about comparing
the findings with similar publications from other sources.
Scope
The focus of the analysis is on the severity of nurse closed claims that satisfied the inclusion criteria
described above. Claim characteristics examined within the report include location of the event,
nurse specialty, type of allegation, and harm or injury.
Unless specifically noted, the tables and charts in Part I of this report include both RN and LPN nurses
closed claims. See Figure 20 on page 38 for a comparative analysis of RN and LPN/LVN closed claims.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
7
Terms
For purposes of this report only, please refer to the terms and explanations below:
2011 claim report – A reference to the prior CNA study, titled “Understanding Nurse Liability,
2006-2010: A Three-part Approach,” www.cna.com/healthcare.
Agency nurse – Any RN or LPN/LVN who provides nursing services as an independent contractor
or as an employee of a staffing or placement service.
Aging services – Specialized facilities or organizations that provide healthcare to a senior population.
Aging services facilities, which also may be referred to as long term care, include but are not limited
to nursing homes, assisted living centers and independent living facilities.
Average total incurred – Indemnity plus expense costs paid by CNA, divided by the number of
closed claims.
Expense payment – Monies paid in the investigation, management and/or defense of a claim.
Incurred payment – The costs or financial obligations, including indemnity and expenses, resulting
from the resolution of a claim.
Indemnity payment – Monies paid on behalf of an insured nurse in the settlement or judgment .
of a claim.
Practitioner – A licensed independent healthcare provider such as a physician, dentist, advanced
practice nurse or physician assistant.
Severity – The average indemnity amount of CNA nurse closed claims included within the dataset.
Limitations
The data analysis within this report is subject to the following limitations and conditions:
– The database includes only closed claims against nurses insured by CNA through the NSO
program, which does not necessarily represent the entire spectrum of nurse activities and nurse
closed claims.
– Noted indemnity payments are only those paid by CNA on behalf of its insured nurses through
the NSO program and do not reflect additional amounts paid by employers, other insurers or
other parties in the form of direct or insurance payments.
– The process of resolving a professional liability claim may take many years. Therefore, claims
included in this report may have arisen from an event that occurred prior to 2010, yet closed
during the period of the report.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
8
Data Analysis
Analysis of claims by licensure type
– Of the 549 nurse closed claims, 88.5 percent involve RNs and 11.5 percent involve LPNs/LVNs.
These percentages reflect the overall proportion of CNA/NSO-insured nurses. While the distri- .
bution of licensure types within the CNA/NSO book of business varies somewhat over time, the
current ratio of our in force business represents 89 percent RNs to 11 percent LPNs/LVNs.
– Claims asserted against LPNs/LVNs resulted in a 58 percent increase in average total incurred,
compared with the 2011 closed claim report. The higher severity was driven by several closed
claims that settled for $250,000 or more, involving infant and pediatric patients with tracheostomies who suffered adverse outcomes in their homes, as illustrated by the following examples:
– An LPN with significant geriatric experience accepted a weekend position as a home
health nurse to earn extra income. The home health agency requested that the nurse take
an assignment providing one-on-one care to a two-year-old child on a ventilator. The LPN
told the agency that the only experience she had with ventilators was assisting geriatric
patients with tracheotomy care. The agency told the nurse to meet the child and “give
caring for the child a try.” On the second visit, the child suffered an apneic episode. The
nurse called 911 but then panicked and could not remember the proper procedure for
removing the child from the ventilator. Manual resuscitation was initiated using a bag
valve mask. The patient experienced an anoxic brain injury and suffers from seizures.
– An experienced pediatric home health LVN arrived at the home of a ventilator-dependent .
one-year-old girl and found the child to be playful but not quite herself. The health record
notes indicated that the child was cranky, her color was not normal and her oxygen saturations were between 91 and 93 percent. Eventually, the child was placed in the crib for a
nap. When she woke up, the ventilator alarm sounded. The child was suctioned and some
material was retrieved, but the child continued to exhibit respiratory difficulties. The nurse
removed the tracheostomy tube and passed a suction catheter through the tracheostomy,
encountering no obstruction or material. She reinserted the tracheostomy tube and .
suctioned again, but nothing was retrieved. Via ambulance, the patient was taken to the
emergency department, where eventually the tracheostomy tube was reinserted correctly.
Due to the lack of sufficient oxygen during the nurse’s attempt to reinsert the tracheostomy
tube and the delay in recognizing the child’s respiratory difficulties, the child suffered .
profound neurological brain damage. The patient’s experts testified that according to the
documentation, the child was already having respiratory difficulty prior to the nap.
Therefore, the nurse should have been more proactive.
– For additional analysis of LPN/LVN closed claims, see Figure 20 on page 38.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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1A CLOSED CLAIMS BY NURSE LICENSURE TYPE
(Indemnity and Expenses for Closed Claims with Paid Indemnity ≥ $10,000)
Licensure type
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Average paid
expense
Average total
incurred
Registered nurse
88.5%
$80,428,847
$165,491
$36,424
$201,916
Licensed practical/ .
vocational nurse
11.5%
$9,928,686
$157,598
$42,173
$199,771
Overall
100.0%
$90,357,533
$164,586
$37,084
$201,670
1B COMPARISON OF 2011 AND 2015 CLAIM DISTRIBUTION
BY NURSE LICENSURE TYPE
(Closed Claims with Paid Indemnity ≥ $10,000)
n 2011 n 2015
91.9%
88.5%
Registered nurse
Licensed practical/vocational nurse
8.1%
11.5%
Analysis of severity by year
– Figure 2 displays severity and average paid expense for nurse closed claims from 2010-2014
with an indemnity payment of $10,000 or greater. The year with the highest severity was 2013,
during which 17 claims (10.4 percent) resulted in an indemnity payment of $500,000 or above.
– Although the graph lines fluctuate throughout the noted time period, the overall cost of .
managing and defending a nurse claim over the past five years appears to be stable.
2
SEVERITY AND AVERAGE PAID EXPENSES BY YEAR CLOSED
(Closed Claims with Paid Indemnity ≥ $10,000)
2010
2011
2012
2013
2014
$200,000
$150,000
$100,000
$50,000
Average paid indemnity
Average paid expense
Average total paid
Linear (average paid indemnity)
Linear (average paid expense)
Linear (average total paid)
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Nurse closed claims with expense payments only
– Figure 3 displays average paid expenses for nurse closed claims with no indemnity payment
and paid expenses of one dollar or greater over five years, with the highest average paid
expense occurring in 2013 and 2014.
– The chart depicts closed claims that were successfully defended on behalf of the nurse, dismissed
or withdrawn by the plaintiff during the investigative or discovery process, or terminated by
the court in favor of the defendant prior to trial. An example of a successful defense against a
nurse resulting in no indemnity payment can be found on page 37.
3
AVERAGE PAID EXPENSE FOR CLOSED CLAIMS
(No Indemnity Paid by Year Closed with Paid Expenses ≥ $1.00)
2010
2011
2012
2013
2014
Average paid expense
Linear (average paid expense)
$10,000
$8,000
$6,000
$4,000
Figure 4 reveals that for both the 2011 and 2015 claim analyses, the highest percentage of closed
claims have a paid indemnity between $10,000 and $99,999. The two analyses show similar percent- .
ages of closed claims in the $750,000-$999,999 and $1,000,000 paid indemnity categories.
4A COMPARISON OF 2011 AND 2015 CLAIM DISTRIBUTION
(Closed Claims with Paid Indemnity ≥ $10,000)
$1,000,000
3.5%
3.1%
$750,000 – $999,999
2.1%
2.7%
$500,000 – $749,999
2.1%
3.8%
$250,000 – $499,999
$100,000 – $249,999
n 2011 n 2015
11.2%
10.6%
24.8%
20.9%
56.2%
58.8%
$10,000 – $99,999
4B COMPARISON OF 2011 AND 2015 AVERAGE PAID INDEMNITY
(Closed Claims with Paid Indemnity ≥ $10,000)
Average paid indemnity
n 2011 n 2015
$161,501
$164,586
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of severity by nurse specialty
– The nurse specialties consistently experiencing the highest severity in both past and present
CNA/NSO closed claim reports are neurology and obstetrics, due to the cost of lifelong, oneon-one nursing care required by the injured party. Examples of these closed claims include:
– Failure of a nurse to monitor and timely report blood levels on a 30-year-old patient
receiving anticoagulation therapy. The patient suffered an eight-centimeter hematoma
within the right frontal lobe of her brain due to the delay, leaving her permanently and
totally disabled.
– Improper management of an obstetrical patient by a nurse who attempted to reinsert a
prolapsed umbilical cord prior to delivery.
– The adult medical/surgical specialty continues to represent the highest percentage of closed
claims. However, as predicted in the 2011 claim report, claim frequency has increased in non- .
hospital-based specialties such as home health/hospice, reflecting the overall migration of
healthcare toward outpatient settings. One consequence of this shift is that, more than ever,
home health/hospice nurses must be in frequent communication with the patient’s practitioner,
as illustrated by the following closed claims:
– The home health nurse failed to notify the practitioner of the patient’s medical decline. .
The patient was on intravenous antibiotics for bacterial endocarditis, and on two visits to
the patient’s house, the nurse failed to notify the referring cardiologist of the patient’s
extremely abnormal vital signs.
– Against practitioner orders, the nurse delayed administering pain medication to a hospice
patient, resulting in unnecessary suffering.
– There were two occupational/employee health closed claims:
– One closed claim involves failure to properly assess and advise an employee with .
a history of uncontrolled high blood pressure and a severe headache to seek medical
treatment. The nurse instructed the employee to go home, take over-the-counter pain
medications and rest. Later that night the patient suffered a severe cardiovascular accident.
– The second closed claim involves the nurse’s failure to properly maintain correct infection
prevention practices while administering an influenza intramuscular injection, causing .
an employee to suffer from cellulitis. The nurse neither cleaned the injection site nor used
gloves during the injection.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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5A SEVERITY BY NURSE SPECIALTY
(Closed Claims with Paid Indemnity ≥ $10,000)
Nurse specialty
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Neurology/neurosurgery
0.4%
$1,077,000
$538,500
Occupational/employee health
0.4%
$827,980
$413,990
Obstetrics
9.8%
$21,441,467
$397,064
Neonatal/nursery – well baby
1.1%
$1,325,000
$220,833
Plastic/reconstructive surgery
1.6%
$1,752,332
$194,704
Emergency/urgent care
10.7%
$10,750,689
$182,215
Home health/hospice
12.4%
$11,794,067
$173,442
Pediatric/adolescent
2.0%
$1,710,250
$155,477
Behavioral health
2.4%
$1,850,249
$142,327
Adult medical/surgical
36.1%
$27,392,453
$138,346
Wound care in an office setting
0.7%
$435,250
$108,813
Gerontology – in aging services facility
16.4%
$7,736,782
$85,964
Correctional health
3.6%
$1,501,639
$75,082
Aesthetic/cosmetic
2.4%
$762,375
$58,644
Overall
100.00%
$90,357,533
$164,586
5B COMPARISON OF 2011 AND 2015 CLAIM DISTRIBUTION
BY NURSE SPECIALTY
(Closed Claims with Paid Indemnity ≥ $10,000)
n 2011 n 2015
Obstetrics
10.3%
9.8%
Emergency/urgent care
9.7%
10.7%
Home health/hospice
8.9%
12.4%
40.1%
36.1%
Adult medical/surgical
Gerontology – in aging services facility
18.0%
16.4%
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of severity by location
– The locations with the highest distribution of closed claims, accounting for 58.5 percent of all
closed claims, are hospital-inpatient medical, aging services, patient’s home and hospital –
inpatient surgical service-related. These findings are consistent with the 2011 claim report.
– The closed claims with the highest severity, excluding obstetrics – inpatient perinatal services,
tend to be relatively infrequent. Several claims arose from services provided in non-traditional
settings, such as the nurse’s residence or a hotel. These closed claims usually involve failure to
fulfill the core responsibilities, duties and/or expectations of licensed nurses, as the following
examples illustrate:
– A patient underwent several plastic surgeries in one day. After more than 12 hours of .
surgery, the patient was released to the care of a nurse, who tended to her in a local
hotel room. The nurse stayed with the patient overnight, but failed to notify the attend- .
ing practitioner and family members of meaningful changes in her condition and failed .
to react to emergent conditions requiring timely transfer of the patient to an acute care .
facility. The nurse’s delay in care and failure to recognize changes in the patient’s medical
condition was the ultimate cause of the patient’s death.
– A registered nurse was hired by a not-for-profit organization to train patient care tech- .
nicians to care for disabled children participating in an overnight field trip. The nurse
failed to explain to the patient care technicians how to properly set up the continuous
positive airway pressure machine for one child, who died in her sleep.
– Many of the closed claims in the obstetrics location involve permanent neurological damage,
resulting in an indemnity payment at full policy limits. Additional obstetrics-related closed claims
are analyzed in Figure 15 on page 33.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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6A ANALYSIS OF SEVERITY BY LOCATION
(Closed Claims with Paid Indemnity ≥ $10,000)
* “Other” claim locations include working as an independent contractor for a patient recuperating in a hotel following extensive plastic surgery, and
working as a consultant for a not-for-profit organization.
Location
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Occupational health center
0.4%
$827,980
$413,990
Obstetrics – inpatient perinatal services
8.2%
$17,993,967
$399,866
Nurse residence/home
0.5%
$1,040,000
$346,667
Hospital – obstetrics .
(Cesarean suite or PACU)
1.1%
$1,772,500
$295,417
*Other
0.4%
$550,000
$275,000
Telemetry unit – hospital-based
0.2%
$218,750
$218,750
Hospital – (PACU)
1.3%
$1,372,500
$196,071
Hospital – nursery
0.9%
$925,000
$185,000
Emergency department – hospital-related
10.6%
$10,725,689
$184,926
Radiology – inpatient diagnostic
0.4%
$330,000
$165,000
Transport services
0.2%
$162,500
$162,500
Patient’s home
12.6%
$10,970,067
$158,986
Hospital – inpatient medical services
17.7%
$15,336,650
$158,110
Hospital – inpatient surgical services
11.3%
$9,508,085
$153,356
Behavioral/psychiatric health
2.4%
$1,850,249
$142,327
Spa
0.7%
$460,000
$115,000
Aging services
16.9%
$9,735,782
$104,686
Practitioner office practice
4.6%
$2,579,677
$103,187
Correctional health – inpatient or outpatient
3.8%
$1,812,639
$86,316
Ambulatory surgery
2.9%
$1,169,498
$73,094
School (preschool through university)
1.1%
$407,000
$67,833
Hospital – operating room/suite
1.5%
$490,000
$61,250
Dialysis – freestanding
0.2%
$50,000
$50,000
Clinic – hospital outpatient
0.2%
$45,000
$45,000
Freestanding specialty care facility .
(non-ambulatory)
0.2%
$24,000
$24,000
Overall
100.0%
$90,357,533
$164,586
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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6B COMPARISON OF 2011 AND 2015 CLAIM DISTRIBUTION
BY LOCATION
(Closed Claims with Paid Indemnity ≥ $10,000)
Emergency department – hospital-related
Patient’s home
n 2011 n 2015
9.3%
10.6%
8.9%
12.6%
20.2%
17.7%
Hospital – inpatient medical services
Hospital – inpatient surgical services
Aging services
10.3%
11.3%
18.4%
16.9%
The percentage of closed claims involving
medication administration has declined
by half since the 2011 claim report, while
severity has approximately doubled.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of Severity by Allegation
Figures 7A and 7B contain the average and total paid indemnities for all allegation categories.
Allegation subcategories are listed in Figures 8-12.
Allegation by category
– The percentage of closed claims involving medication administration has declined by half since
the 2011 claim report, while severity has approximately doubled. This decrease in frequency
correlates with recent technological advances and error-reduction initiatives, such as bar-coding
of medications and computerized order entry. However, the existence of these highly publicized
drug safety efforts may make it more difficult to defend medication administration-related claims
where nurses bypassed such controls, as illustrated by the following examples:
– An agency nurse working in an emergency department gave 16 milligrams of undiluted
hydromorphone in three minutes by intravenous push instead of an intravenous drip over
several hours. When the nurse returned 30 minutes after giving the hydromorphone, the
patient, who was not on a cardiac monitor, was pulseless and not breathing. Despite
resuscitation efforts, the patient died. The nurse testified that she was unfamiliar with the
potency of hydromorphone and misread the practitioner’s orders.
– A geriatric nurse working in an aging services setting ignored the facility’s policies and
procedures on medication administration and gave a methadone injection to the wrong
patient, which caused fatal respiratory arrest.
– Allegations related to treatment and care continue to represent the highest percentage of
closed claims. Claims in this category occur in all specialties and locations, but the highest
percentage of closed claims involve adult/medical surgical, gerontology, home health/hospice
and obstetrics.
– During the evening shift, an intensive care unit (ICU) patient being weaned off the venti- .
lator became agitated and had difficulty maintaining her oxygen saturation levels. The
nurse spent most of his time caring for the patient, making several telephone calls
throughout his shift to the practitioner for additional orders. The nurse administered a .
sedative, per practitioner orders, and stepped away from the patient to attend a meeting .
in the unit’s conference room. As a result, the cardiac monitor alarm sounded for eight
minutes before the nurse heard it. When he returned, the patient was in asystole and
later died.
– A 38-year-old female patient was admitted to the medical intensive care unit with a .
diagnosis of pneumonia and an extensive and complicated history of cardiac illness,
including endocarditis. She was receiving a large amount of diuretics for fluid retention. .
Her practitioner, believing she was stable, allowed her to use a bedside commode .
while on a cardiac monitor. When the patient ambulated to use the commode, the cardiac
monitor would indicate the patient was in ventricular tachycardia, but when the nurse
checked on the patient, she appeared fine. The nurse discussed the rhythm with her
charge nurse, and both agreed that the change in the cardiac rhythm was associated .
with patient movement rather than ventricular tachycardia. However, a few hours later, .
the patient’s cardiac monitor indicated the patient was in ventricular fibrillation. When .
the nurse went to check, the patient was observed to be cyanotic, with distended neck
veins. A code team was called, but the patient expired.
– Many of the closed claims in the patients’ rights/patient abuse/professional conduct category
involve falls, which occurred because a nurse failed to follow fall-prevention policies polices,
thereby violating the patient’s right to a safe environment.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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7A SEVERITY BY ALLEGATION CATEGORY
(Closed Claims with Paid Indemnity ≥ $10,000)
Allegation category
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Medication administration
8.0%
$9,372,227
$213,005
Monitoring
13.8%
$13,977,772
$183,918
Treatment/care
45.9%
$45,053,823
$178,785
Scope of practice
2.9%
$2,458,777
$153,674
Assessment
15.7%
$11,099,510
$129,064
Documentation
0.5%
$368,334
$122,778
Patients’ rights/patient abuse/ .
professional conduct
13.1%
$8,027,090
$111,487
Overall
100.0%
$90,357,533
$164,586
7B COMPARISON OF 2011 AND 2015 CLAIM DISTRIBUTION
BY ALLEGATIONS
(Closed Claims with Paid Indemnity ≥ $10,000)
Medication administration
Monitoring
14.7%
8.0%
6.8%
13.8%
58.5%
Treatment/care
45.9%
12.6%
15.7%
Assessment
Patients’ rights/patient abuse/
professional conduct
n 2011 n 2015
5.4%
13.1%
Assessment-related closed claims often
involve nurses failing to identify the worsening
of a pressure ulcer or contact the treating
practitioner for additional medical treatment.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of Allegation Sub-categories
Figures 8-12 examine allegation sub-categories in greater detail. Percentages in Figures 8-12 relate
to the indicated allegation category, rather than the overall dataset.
Allegations related to assessment
– Closed claims alleging failure to properly or fully complete the patient assessment reflect the
highest severity.
– Over one-third of the closed claims in this category allege a failure to adequately assess inmates
in a correctional facility, as illustrated in the following case scenarios:
– The patient had an extensive personal and family history of high blood pressure. After .
an altercation with other inmates and correctional staff, he complained of a headache, .
was drowsy and had slurred speech. The correctional nurse was called to evaluate the
patient and did so hurriedly, because the patient was in a secured area. The nurse
obtained orders for a baby aspirin from the facility’s medical director and had the patient
transferred to the infirmary. Thirty minutes later, the patient was unable to follow commands or open his mouth, and his movements were spastic with weakness in both hands.
He was sent to the local emergency department and was diagnosed with a large left
basal ganglia bleed due to uncontrolled hypertension. The patient is now in a permanent
vegetative state.
– The insured was an admission nurse working in a correctional facility, where she would see
up to 400 patients a month. Her responsibilities included obtaining information from
patients by conducting a brief medical assessment and then referring patients to the
medical director for any medication needs and follow-up. One patient complained of leg
weakness upon admission, but the nurse failed to document his statement. Two days
later, the patient claimed that he could not walk. When he was examined by the facility
medical director, the patient was found to have a spinal abscess requiring immediate
medical intervention.
– Most of the assessment-related closed claims involve a failure to asses the need for medical
intervention. These closed claims often involve nurses failing to identify the worsening of a
pressure ulcer or contact the treating practitioner for additional medical treatment.
8
SEVERITY OF ALLEGATIONS RELATED TO ASSESSMENT
(Closed Claims with Paid Indemnity ≥ $10,000)
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Failure to properly or fully complete .
the patient assessment
19.8%
$4,454,555
$262,033
Delayed or untimely patient assessment
3.5%
$380,000
$126,667
Failure to assess the need .
for medical intervention
60.5%
$5,656,080
$108,771
Failure to consider/assess patient’s .
expressed complaints/symptoms
11.6%
$482,375
$48,238
Failure to reassess patient after any .
change in medical condition
4.7%
$126,500
$31,625
Overall
100.0%
$11,099,510
$129,064
Allegation
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
19
Allegations related to monitoring
– Failure to monitor and timely report patient vital signs represents the highest severity in the
monitoring sub-category, including two claims that closed at policy limits. Both closed claims
involve nurses who failed to monitor vital signs after patients returned from surgery, as
described below:
– A nurse cared for a patient who had an emergent appendectomy and coded afterward .
in the PACU. The patient was admitted to a regular unmonitored hospital bed during the
evening hours and was not placed on any cardiac or pulse oximetry monitoring. The
nurse made few entries during the night regarding the patient and failed to record any
vital signs. The patient coded again and the family insisted the patient be transferred to
another hospital to recover.
– A nurse failed to request a continuous pulse oximetry monitor for the patient after .
surgery. The patient was at high risk for decreased oxygen levels related to surgery,
increased hydromorphone levels and a self-reported history of sleep apnea. The nurse
assessed the patient every 15 minutes for the first hour, per organizational policy, without .
any problems. However, after the nurse switched to every-30-minute assessment, the
patient was found pulseless and unresponsive. He later died in the ICU due to compli- .
cations of anoxic brain injury.
– Claims alleging failure to monitor and timely report blood levels for medications involve nurses
who neglected to properly watch patients on high-risk drugs such as insulin and anticoagulants,
as described below:
– A critically ill, intubated, diabetic patient was admitted to the ICU on a glycemic control
insulin infusion protocol. The nurse signed the orders, but failed to check the patient’s
blood glucose level every two hours per protocol. Four hours elapsed before the nurse
realized that she had not performed a finger-stick blood sugar test on the patient. When
the levels were checked, the patient’s glucose was 11 mg/dl and emergency hypogly- .
cemic measures were initiated. The patient, who suffered from metabolic encephalopathy
secondary to hypoglycemia, later died.
– A patient in an acute care rehabilitation facility following knee replacement surgery was
placed on Coumadin® as a result of her immobilization, as well as Septra® to treat a urinary
tract infection. The nurse was responsible for monitoring the INR levels but was unfamiliar
with the interaction of Septra® and Coumadin®. She neither monitored the blood levels
nor contacted the prescribing practitioner to obtain an order for a new antibiotic for the
patient. The patient was given each medication for three days when the patient’s daughter
noted a change in her mental status. Suffering from an intracranial hemorrhage, the
patient was transferred to the nearest medical center and died two days later.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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9
SEVERITY OF ALLEGATIONS RELATED TO MONITORING
(Closed Claims with Paid Indemnity ≥ $10,000)
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Failure to monitor and timely .
report patient vital signs
11.8%
$3,395,000
$377,222
Failure to monitor and timely .
report blood levels for medications
11.8%
$2,254,833
$250,537
Failure to monitor/report changes in the patient’s
condition for high-risk patient care areas
52.6%
$6,291,231
$157,281
Failure to monitor/report changes .
in the patient’s medical/emotional .
condition to practitioner
21.1%
$1,903,375
$118,961
Failure to monitor results of .
ordered tests, consultations or referrals, .
or report them to practitioner
2.6%
$133,333
$66,667
Overall
100.0%
$13,977,772
$183,918
Allegation
Closed claims involving the failure to invoke
or utilize the chain of command account
for
7.5% of the treatment and care closed
claims, and have a higher average severity.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Allegations related to treatment and care
– Closed claims relating to pregnancy or obstetrical complications collectively comprise 19.0 .
percent of all treatment and care allegations. While the majority of these closed claims involve
nurses working in labor and delivery units within hospitals, some incidents occurred in practitioner offices, emergency departments, ICUs and correctional facilities, where nurses failed to
manage pregnancy or obstetrical complications due to lack of training in obstetrical emergencies.
(Obstetrics closed claims are analyzed in Figure 15 on page 33.)
– Nurses are responsible for invoking the medical chain of command when necessary, in order to
trigger a practitioner’s intervention for the patient. Closed claims involving the failure to invoke
or utilize the chain of command account for 7.5 percent of the treatment and care closed claims,
and reflect a high average severity. Both the frequency and severity of this subcategory have
increased slightly since the 2011 claim report. Approximately half of the chain of command
closed claims occurred in labor and delivery units, with nearly all injured patients either dying or
sustaining permanent total disability.
– In the 2011 claim report, retained foreign body closed claims had an overall severity of less than
$40,000 and represented less than 4 percent of the total treatment and care allegations. In the
current report, retained foreign body closed claims comprise 5.2 percent of the total treatment
and care allegations, and severity has grown to more than $60,000. Retained objects included
intravenous catheters, sponges and gauze.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
22
Because of the size and diversity of the treatment and care allegation category, this chart is limited to
allegations with a severity of $50,000 or greater. Thus, there are no totals at the bottom of the table.
10 SEVERITY OF ALLEGATIONS RELATED TO TREATMENT AND CARE
(Closed Claims with Paid Indemnity ≥ $50,000)
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Failure to timely report complication .
of pregnancy/labor to practitioner
4.4%
$6,354,950
$577,723
Failure to identify and report observations, .
findings or change in condition
1.6%
$1,487,500
$371,875
Failure to invoke/utilize chain of command
7.5%
$6,698,551
$352,555
Delay in implementing practitioner orders
0.8%
$690,000
$345,000
Improper or untimely nursing management .
of obstetrical patient/complication
7.9%
$6,257,916
$312,896
Improper management of assaultive/ .
abusive/aggressive patient
0.8%
$500,000
$250,000
Failure to timely transfuse ordered .
blood/blood product
0.4%
$218,750
$218,750
Abandonment of patient
1.2%
$585,000
$195,000
Failure to timely obtain practitioner orders to
perform necessary additional treatment(s)
0.4%
$187,500
$187,500
Failure to notify practitioner .
of patient’s condition
5.6%
$2,573,557
$183,826
Improper or untimely nursing management .
of medical patient or medical complication
11.9%
$5,394,475
$179,816
Improper or untimely nursing management .
of behavioral health patient
4.8%
$2,041,667
$170,139
Treatment and care provided to .
the wrong patient
0.4%
$160,000
$160,000
Failure to document observations, .
treatment or practitioner contact
0.4%
$140,000
$140,000
Improper or untimely nursing management .
of surgical or anesthesia complication
4.0%
$1,294,667
$129,467
Failure to carry out practitioner orders .
for care and treatment
4.4%
$1,323,500
$120,318
Improper nursing technique or negligent .
performance of treatment, resulting in injury
11.5%
$3,363,000
$115,966
Equipment user error
5.6%
$1,621,457
$115,818
Failure to report medical complication .
or change in medical patient’s condition
1.2%
$273,500
$91,167
Failure to follow critical pathways
2.4%
$524,741
$87,457
Failure to timely report behavioral health .
complication/change
0.4%
$86,000
$86,000
Improper or untimely management .
of aging services resident
5.6%
$1,196,349
$85,454
Failure to respond to .
equipment warning alarms
0.4%
$66,660
$66,660
Failure to timely implement .
established treatment protocols
0.4%
$66,500
$66,500
Retained foreign body
5.2%
$784,166
$60,320
Allegation
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
23
Claim Scenario: Delay in Implementing Provider Orders
The patient was a 38-year-old female admitted for a Cesarean
One hour later, upon arrival of the oncoming shift, the ICU
delivery of twins. The babies were delivered without incident,
nurse reported to the oncoming nurse that the blood had still
but the patient experienced excessive post-operative vaginal
not been delivered. Even though both nurses were concerned
bleeding attributed to placental accreta.
about the situation, neither nurse called to ascertain the blood’s
location. Fifteen minutes into the oncoming nurse’s shift, the
An emergency total abdominal hysterectomy was performed
administration of one unit of packed red blood cells was started.
in an attempt to control the bleeding. After surgery, the patient,
While the blood was transfusing, the patient went into respira-
who appeared stable, was transferred to the ICU with blood
tory distress, and the admitting ICU practitioner was notified.
pressure of 110/60 mmHG. The receiving ICU nurse had orders
to transfuse the patient with two units of fresh frozen plasma
Later that evening, the patient underwent a second abdominal
and monitor vital signs every 30 minutes. After the first unit of
surgery. Due to her extensive hypovolemia, she slipped into a
plasma was given, the patient’s blood pressure was 108/59
coma post-operatively and currently remains in a vegetative
mmHG. She was assessed by the attending ICU practitioner,
state. During deposition, the admitting ICU practitioner testified
who ordered a complete blood count to be conducted after the
that he was not informed of the second laboratory results or
second unit of fresh frozen plasma. The ICU practitioner noted
the patient’s vital signs until the patient went into respiratory
that the patient post-surgical hemoglobin and hematocrit levels
distress. The claim asserted against our nurse settled for greater
were 7.4 gm/dL and 22 percent respectively. However, one hour
than $600,000. Several other healthcare practitioners were .
after the second unit of plasma was given, the patient’s hemo-
also included in the lawsuit, but their settlement amounts were
globin was 5.9 gm/dL, and hematocrit was 17.7 percent. The
not available.
nurse documented the results in the health record, but did not
notify the ICU practitioner because he assumed the practitioner
was returning to the unit to reassess the patient. Two hours
after the second unit of plasma, the patient’s blood pressure was
reported as 63/21 mmHG. The nurse notified the on-call resident
of the blood pressure and received an order for stat transfusion
of two units of packed red blood cells. The blood bank records
indicated that the blood was available 20 minutes after stat
order was received.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
24
Allegations related to medication administration
Significant improvements in medication administration technology have occurred since 1999, when
the Institute of Medicine released its groundbreaking report, “To Err is Human: Building a Safer
Health System,” http://iom.nationalacademies.org/reports/1999/to-err-is-human-building-a-saferhealth-system.aspx. This publication created widespread awareness of drug administration errors.
While the percentage of closed claims involving this allegation has gradually decreased, severity
continues to rise.
– Errors such as wrong rate of flow, wrong route, wrong dose, wrong medication and wrong patient
are often caused by poor communication with the pharmacist and/or prescribing practitioner,
failure to clarify the medication order, excessive workload or preoccupation/distraction.
– Of the 44 medication administration-related closed claims in the dataset, 16 (36 percent) involve
narcotics, as in the following examples:
– During a busy evening shift, a nurse administered hydromorphone to the patient .
intravenously instead of by mouth, as the practitioner had ordered. The patient went into
respiratory arrest minutes after receiving the medication.
– A patient in an aging services facility was receiving hospice care and died after receiving .
a methadone injection intended for another hospice patient.
– Many of the medication administration errors involve nurses using “work-arounds” to bypass
the facility’s established safety procedures, such as medication bar-coding or other automated
processes. Bypassing safety systems or failing to follow established facility policies and procedures makes claims difficult to defend, especially when high-risk drugs are involved.
Many of the medication administration errors
involve nurses using “work-arounds” to bypass
the facility’s established safety procedures.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
25
11 SEVERITY OF ALLEGATIONS RELATED TO MEDICATION ADMINISTRATION
(Closed Claims with Paid Indemnity ≥ $10,000)
Allegation
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Wrong rate of flow
6.8%
$2,033,480
$677,827
Provision of services beyond scope of practice
2.3%
$500,000
$500,000
Wrong route
15.9%
$1,898,000
$271,143
Failure to immediately report/record .
improper administration of medication
4.5%
$538,500
$269,250
Wrong dose
18.2%
$1,674,667
$209,333
Failure to properly monitor or .
maintain intramuscular, .
subcutaneous, or gastric tube site
2.3%
$200,000
$200,000
Failure to recognize contraindication .
and/or known adverse interaction .
between/among ordered medications
9.1%
$781,250
$195,313
Wrong patient
9.1%
$655,000
$163,750
Wrong information .
provided or recorded
2.3%
$121,250
$121,250
Wrong medication
11.4%
$457,750
$91,550
Failure to properly monitor .
and maintain infusion site
2.3%
$90,000
$90,000
Missed dose
6.8%
$246,500
$82,167
Failure to resolve medication question .
with pharmacist and/or practitioner .
prior to administration
6.8%
$155,830
$51,943
Improper technique
2.3%
$20,000
$20,000
Overall
100.0%
$9,372,227
$213,005
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Claim Scenario: Medication Error Resulting in Death
Following a recent hospitalization for complications of meta-
On admission into the hospital, the patient was responsive when
static ovarian cancer, an elderly woman with an extensive history
receiving Narcan®, but as soon as the medication wore off, she
of bipolar disorder was discharged to an aging services facility
suffered from shallow respirations and became unresponsive.
due to her family’s inability to care for her at home. Throughout
By day two of the hospitalization, the patient appeared to be
her stay, her family made several complaints to the administra-
less responsive, but was able to respond to the voices of family
tion regarding the care the patient was receiving and requested
members. On day three, she was unresponsive to painful stimuli,
that the patient be transferred to another facility on numerous
was found without a pulse or heart rate, and pronounced dead.
occasions.
An autopsy was performed, which indicated that the primary
cause of death was an overdose of morphine.     
The LPN on duty the evening of the incident was an agency
nurse who had worked at the facility previously and was aware
When the patient was transferred to the hospital, an investigation
of the facility’s policies and procedures in regard to medication
at the aging services facility revealed that the nurse had made
administration. During the scheduled evening medication admin- .
a medication administration error. The morphine given was
istration round, the nurse was in the patient’s room when she
prescribed for another patient. Because the nurse became dis-
became distracted by a patient from another room requesting
tracted in the middle of the medication administration process,
assistance. When the nurse returned to the patient’s room, she
the morphine had been entered into the correct patient’s medi- .
gave the patient her nightly medications. The patient questioned
cation record but given to another patient. Although there
the number of pills the nurse was giving her, stating that she had
was no record of the patient receiving morphine, the patient’s
never taken “purple pills.” The nurse assured the patient that the
reaction to Narcan®, as well as the results of the urine and
medication was correct and continued with the administration.
blood analysis completed at the hospital where the patient was
transferred, left little doubt as to the medication administration
An hour later, a certified nursing assistant notified the nurse that
error. The claim resolved for greater than $350,000.  
one of her patients was unresponsive. The LPN found the patient
to have a thready pulse and shallow respirations. The facility
called 911, and when the paramedics arrived they administered
Narcan® intravenously, which instantly revived the patient. On
the way to the hospital, the patient told the paramedics that
the nurse had given her four “purple pills” earlier that evening,
which immediately put her to sleep.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
27
Allegations related to patients’ rights,
patient abuse and professional conduct
– Closed claims alleging inappropriate nurse supervision have the highest severity. These closed
claims asserted against directors of nursing involve hiring practices related to clinical staff.
(See Figures 17-18 on page 35 for more information about director of nursing claims.)
– Closed claims alleging violation of patients’ rights include unauthorized release of protected
patient information, as well as denial of care to inmates requesting medical treatment.
– Closed claims alleging violation of patients’ rights to care in a safe environment include failure
to take necessary action to prevent falls, maintain clear hallways, perform pre-employment
screening or ensure that patients were treated with the appropriate level of care. For additional
analysis of fall-related closed claims, see Figure 12B.
– In general, abuse allegations against nurses reflect a relatively low frequency and severity, in
comparison to the overall dataset.
– The average paid indemnity for falls ($81,972) is less than the overall average paid indemnity
for nurse closed claims.
– Closed claims alleging injury due to a failure to take necessary action to prevent falls was a
recurring theme, as in the following examples:
– A resident fell down a flight of stairs because a fire door had been propped open. .
The charge nurse was responsible for ensuring that all doors to the unit were closed.
– While in an acute medical center, an elderly patient was given a sedative prescribed .
by his practitioner. The nurse failed to engage the bed alarm and shut the door of .
the patient’s room. During nursing rounds, the patient was found on the floor, where .
he apparently had been lying for several hours.
12A SEVERITY OF ALLEGATIONS RELATED TO PATIENTS’ RIGHTS,
PATIENT ABUSE AND PROFESSIONAL CONDUCT
(Closed Claims with Paid Indemnity ≥ $10,000)
Allegation
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Inappropriate nurse supervision
2.8%
$1,080,000
$540,000
Violation of patients’ rights
5.6%
$1,159,167
$289,792
Violation of patients’ rights to .
care in a safe environment
75.0%
$5,412,832
$100,238
Sexual abuse by nurse
6.9%
$192,591
$38,518
Verbal abuse by nurse
2.8%
$55,000
$27,500
Physical abuse by nurse
6.9%
$127,500
$25,500
Overall
100.0%
$8,027,090
$111,487
Falls
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
No
88.0%
$84,994,659
$175,972
Yes
12.0%
$5,362,874
$81,256
Overall
100.0%
$90,357,533
$164,586
12B SEVERITY AND FREQUENCY OF FALLS
(Closed Claims with Paid Indemnity ≥ $10,000)
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of Severity by Injury
– The review of claims in this report reveals that comas, which were often due to medication
administration errors, have the highest severity among patient injuries. The high severity reflects
the lifelong medical cost for patients in a persistent vegetative state who require 24-hour nursing
care. Examples include the following:
– An elderly patient admitted to a medical center for generalized weakness was given 80
milligrams of oxycodone, although the drug had not been ordered for her. The nurse
reported the medication administration error immediately to the practitioner and was .
told to monitor the patient for a few hours. One hour later, the patient was discovered to
be in respiratory distress. She suffered a left sub-acute cerebrovascular accident, leaving .
her in a permanent vegetative state.
– A 29-year-old woman was admitted to a behavioral health unit for an apparent attempted
suicide by insulin overdose. The admitting practitioner ordered blood sugar checks every
four hours. However, the nurse was distracted by several additional admissions and failed
to perform the checks during the evening hours. The patient was found unresponsive .
and suffered anoxic brain injury from remaining in a hypoglycemic state for an extended
period of time.
– Death (other than maternal or fetal) is the most common injury, accounting for 42.8 percent .
of the closed claims. When maternal and fetal mortality are included, 44.3 percent of all closed
claims involve a patient death. (Injuries involving death are analyzed in Figure 14 on page 32.)
– Seizures have the second highest severity, driven by two claims that settled at policy limits.
Closed claims in this category involve allegations of failure to properly complete a patient
assessment, invoke the medical chain of command and monitor/report changes in the
patient’s condition.
– Fractures and pressure ulcers are the second and third most common injuries, together
accounting for 12.6 percent of closed claims. Their frequency has increased significantly since
the 2011 claim report. These injuries occur in a variety of locations, especially aging services
and hospital settings.
– Other maternal birth-related injuries include an emergency delivery due to premature labor and
complications resulting from the retention of a sponge during an unplanned Cesarean section.
– In this report, “pain and suffering”are defined as injuries of an emotional nature, such as
depression, anxiety or embarrassment. They may involve temporary or permanent disabilities,
which are discussed in greater detail in Figure 16 on page 34.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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13 SEVERITY BY INJURY
(Closed Claims with Paid Indemnity ≥ $10,000)
* “Other maternal obstetrics-related injury” claims include the failure to identify premature labor and retained foreign body during a Cesarean section.
Injury
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Coma
0.5%
$1,862,500
$620,833
Seizure
0.7%
$2,300,000
$575,000
Neurological deficit/damage
1.3%
$3,874,792
$553,542
Fetal/infant birth-related brain injury
5.3%
$14,638,551
$504,778
Maternal death
0.4%
$900,000
$450,000
Spinal pain/injury – cervical spine and neck
0.2%
$375,000
$375,000
Brain injury other than birth-related
1.8%
$3,629,167
$362,917
Paralysis
1.8%
$3,464,701
$346,470
Cerebrovascular accident (CVA)/stroke
1.3%
$2,355,064
$336,438
Bleeding/hemorrhage
0.7%
$1,261,250
$315,313
Cardiopulmonary arrest
1.6%
$2,429,001
$269,889
Fetal death
1.1%
$1,592,450
$265,408
Loss of limb or use of limb
4.4%
$5,364,333
$223,514
Death (other than maternal or fetal)
42.8%
$32,649,771
$138,935
Head injury
0.7%
$475,000
$118,750
Loss of organ or organ function
2.2%
$1,314,750
$109,563
Burn
4.0%
$2,284,582
$103,845
Infection/abscess/sepsis
5.1%
$2,297,188
$82,042
Eye/ear injury or sensory loss
0.9%
$391,667
$78,333
Pain and suffering
3.1%
$1,162,001
$68,353
Fracture
6.6%
$2,452,166
$68,116
Abrasion/bruise/contusion/laceration
1.3%
$446,000
$63,714
Allergic reaction/anaphylaxis
0.7%
$250,750
$62,688
No injury specific to nurse care, .
but nurse is named
0.2%
$55,000
$55,000
Scar(s)/scarring
1.1%
$326,500
$54,417
Other maternal obstetrics-related injury*
0.5%
$162,500
$54,167
Peripheral vascular ulcer/wound
0.2%
$46,250
$46,250
Compartment syndrome
0.9%
$214,750
$42,950
Pressure ulcer
6.0%
$1,395,509
$42,288
Increase or exacerbation of illness
0.2%
$40,000
$40,000
Cardiac injury (excludes heart attack)
0.4%
$65,000
$32,500
Abuse
0.7%
$123,090
$30,773
Chest pain/angina
0.5%
$75,500
$25,167
Medication-related injury .
not otherwise classified
0.2%
$25,000
$25,000
Heart attack/myocardial infarction
0.2%
$25,000
$25,000
Sprain/strain
0.2%
$20,000
$20,000
Embolism
0.2%
$12,750
$12,750
Overall
100.0%
$90,357,533
$164,586
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of fatal injuries by underlying cause of death
As previously noted, 44.3 percent of all injuries were fatal. Figure 14 provides additional insight into
the causes of these deaths.
Analysis of severity by cause of death
– Allergic reaction/anaphylaxis represented the highest severity of all fatal injuries. The three
closed claims involve administration of a higher-than-prescribed dose of Narcan® or failure to
recognize the patient’s drug allergies prior to administering an antibiotic.
– The three most common causes of death are cardiopulmonary arrest, pressure ulcer and bleeding/
hemorrhage. These results are similar but not identical to the 2011 claim report, in which the
three most frequent causes of death were cardiopulmonary arrest, infection/abscess/sepsis and
bleeding/hemorrhage. Pressure ulcers as a cause of death occur more often in aging services
facilities, where the patient’s comorbidities may impede recovery.
– Suicide as a cause of death is four times more common in the claims reviewed in this report
than in the 2011 claim report. All closed claims involve improper nursing management of a
behavioral health patient in a variety of settings, from behavioral health and correctional facilities
to emergency departments and patients’ homes. Most patients in this category were on facility- .
established suicide precautions but were allowed to retain unsafe items (such as plastic bags,
combs or pens) or were left in high-risk areas (such as bathrooms and public lobbies) without
supervision. The following suicide-related closed claim is just one of several:
– The patient was brought to the emergency department by police and family because .
of suicidal ideation. On arrival, he was placed in an observation room outfitted with two
video cameras, which had a live feed to a monitor at the nurses’ station. While in the
observation room, he hanged himself with a sheet and died.
The three most common causes of death
are cardiopulmonary arrest, pressure ulcer
and bleeding/hemorrhage.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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14 IDENTIFIED CAUSE OF DEATH
(Closed Claims with Paid Indemnity ≥ $10,000)
Identified cause of death
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Allergic reaction/anaphylaxis
1.2%
$925,000
$308,333
Brain injury other than birth-related
0.4%
$262,500
$262,500
Fetal death
3.3%
$2,092,916
$261,615
Congestive heart failure
0.4%
$250,000
$250,000
Aneurysm
0.8%
$480,000
$240,000
Cardiopulmonary arrest
25.5%
$14,301,670
$230,672
Embolism
2.5%
$1,147,600
$191,267
Aspiration
3.7%
$1,601,000
$177,889
Suicide
6.6%
$2,693,583
$168,349
Meningitis
1.2%
$500,000
$166,667
Injury resulting from elopement
1.2%
$456,667
$152,222
Cardiac injury
1.6%
$572,500
$143,125
Bleeding/hemorrhage
11.9%
$4,107,200
$141,628
Abrasion/bruise/contusion/laceration
0.8%
$250,000
$125,000
Maternal death
0.8%
$242,500
$121,250
Heart attack/myocardial infarction
0.8%
$170,950
$85,475
Medication-related injury .
not otherwise classified
0.8%
$163,330
$81,665
Fracture
4.1%
$692,150
$69,215
Infection/abscess/sepsis
7.8%
$1,195,740
$62,934
Cancer
0.4%
$60,000
$60,000
Hypothermia
0.4%
$58,250
$58,250
Fetal/infant birth-related brain injury
0.8%
$112,500
$56,250
Pressure ulcer
13.6%
$1,847,999
$56,000
Dehydration/malnutrition
0.8%
$103,333
$51,667
CVA/stroke
2.1%
$255,000
$51,000
Pneumonia/respiratory infection
3.3%
$360,833
$45,104
Loss of organ or organ function
1.2%
$125,000
$41,667
Coma
0.4%
$37,500
$37,500
Head injury
0.4%
$26,500
$26,500
Increase or exacerbation of illness
0.8%
$50,000
$25,000
Overall
100.0%
$35,142,221
$144,618
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of obstetrics-related injuries
Not all birth-related closed claims occurred in obstetrical locations. Injuries to the mother or baby
also occurred in the emergency department, adult medical/surgical units, post-anesthesia care units,
critical care units, outpatient care locations and patients’ homes.
– Of all obstetrical injuries, fetal/birth-related brain injuries demonstrate both the highest percent- .
age of closed claims and the highest severity. In a number of closed claims, the baby suffered
permanent disability, requiring lifelong ongoing nursing care. These obstetrics-related closed
claims involve one or more of the following nursing errors:
– Failure to invoke the chain of command.
– Failure to timely report complication of pregnancy/labor to a practitioner.
– Failure to monitor and timely report the mother’s and/or baby’s vital signs.
– Failure to identify and report observations, findings or changes in condition.
– Improper or untimely nursing management of an obstetrical patient/complication.
– The maternal deaths resulted from complications, as in the following claim:
– A patient with a history of chronic hypertension, preeclampsia and HELLP syndrome
delivered a child via Cesarean section. While in the recovery room, she developed new
symptoms, became unresponsive, and demonstrated decreased saturation levels and
shallow respiration. The nurse responsible for the patient’s care failed to timely and
appropriately respond to this change, which resulted in the patient’s death.
– Of the three maternal obstetrics-related injuries, one occurred in an obstetrician’s office and
two occurred in the labor and delivery departments. These closed claims primarily involve:
– Sepsis due to an untreated bladder infection.
– Complications from a retained sponge following a Cesarean section.
– Complications during delivery following premature labor.
– The average obstetrics-related closed claim severity of $432,338 is more than twice the dataset’s
overall average severity of $164,586.
– Page 24 contains a more detailed obstetric case scenario.
15 SEVERITY OF OBSTETRICS CLAIMS BY INJURY
(Closed Claims with Paid Indemnity ≥ $10,000)
Injury
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Fetal/infant birth-related brain injury
72.5%
$14,638,551
$504,778
Maternal death
5.0%
$900,000
$450,000
Fetal death
15.0%
$1,592,450
$265,408
Maternal obstetrics-related injury
7.5%
$162,500
$54,167
Overall
100.0%
$17,293,501
$432,338
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
33
Analysis of severity by disability outcome
– Permanent total disability is the outcome with the highest severity. This result is expected, as
permanently disabled individuals require significant medical and social support for the remainder
of their lives. This finding is consistent with the 2011 claim report.
– Closed claims involving patient deaths have the second highest severity, which remains consistent
with the 2011 claim report. The relatively high severity for closed claims where the patient died
may be associated with compensation to survivors and/or aggravating circumstances, such as
allegations that the nurse abandoned the patient or failed to follow practitioner orders.
– Injuries associated with permanent total disability include brain injuries (both non-birth and birth- .
related), paralysis, loss of limb or use of limb, and cardiovascular accident/stroke. The permanent
total disability claims were included in the following allegation categories:
– Treatment and care: 50.6 percent
– Monitoring: 16.5 percent
– Assessment: 11.4 percent
– Medication administration: 8.9 percent
– All other categories: 12.7 percent
16 SEVERITY BY DISABILITY
(Closed Claims with Paid Indemnity ≥ $10,000)
Disability
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Permanent total disability
14.4%
$33,264,933
$421,075
Death
44.3%
$35,142,221
$144,618
Temporary total disability
3.3%
$2,218,250
$123,236
Permanent partial disability
22.6%
$13,310,830
$107,345
Temporary partial disability
15.5%
$6,421,299
$75,545
Overall
100.0%
$90,357,533
$164,586
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Analysis of director of nursing (DON) closed claims
The majority of DON professional liability closed claims involve performance of managerial and/or
administrative services, such as hiring. These allegations are based upon the assumption that the
DON is personally responsible for the actions of the members of the nursing care staff and for the
care of each patient or resident. Of the total nurse closed claims, 5.7 percent involve a director of
nursing, mostly in aging services settings.
– The severity of DON closed claims ($96,371) is significantly lower than the dataset’s overall
severity ($164,586).
– DON claims involving death are both relatively common (67.7 percent) and costly ($115,275),
which is consistent with the 2011 claim report.
17 SEVERITY OF DIRECTOR OF NURSING CLAIMS BY NURSE SPECIALTY
(Closed Claims with Paid Indemnity ≥ $10,000)
Nurse specialty
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Adult medical/surgical
3.2%
$1,000,000
$1,000,000
Gerontology (in aging services facility)
96.8%
$1,987,516
$66,251
Overall
100.0%
$2,987,516
$96,371
18 SEVERITY OF DIRECTOR OF NURSING CLAIMS BY INJURY
(Closed Claims with Paid Indemnity ≥ $10,000)
Injury
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Death
67.7%
$2,420,766
$115,275
Loss of limb or use of limb
3.2%
$112,500
$112,500
Fracture
9.7%
$249,250
$83,083
Pressure ulcer
6.5%
$80,000
$40,000
Infection/abscess/sepsis
6.5%
$80,000
$40,000
Abrasion/bruise/contusion/laceration
3.2%
$25,000
$25,000
Abuse
3.2%
$20,000
$20,000
Overall
100.0%
$2,987,516
$96,371
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
35
Claims related to agency nurses
– Agency nurses are involved in 23.9 percent of the closed claims.
– The severity for agency nurse closed claims is $186,430. For purposes of comparison, the severity
for all non-agency nurse closed claims is $157,740, while the severity for all nurse closed claims
included in the report is $164,586.
19 SEVERITY OF AGENCY NURSE CLAIMS BY AGENCY TYPE
(Closed Claims with Paid Indemnity ≥ $10,000)
Agency type
Percentage of
closed claims
Total paid
indemnity
Average paid
indemnity
Temporary staffing agency
7.7%
$9,034,244
$215,101
Individually contracted nurse
4.6%
$4,712,959
$188,518
Home care agency
11.1%
$10,195,067
$167,132
Hospice care agency
0.5%
$480,000
$160,000
Total agency
23.9%
$24,422,270
$186,430
Total non-agency
76.1%
$65,935,263
$157,740
Overall
100.0%
$90,357,533
$164,586
Agency nurses are involved in
23.9%
of closed claims, and the severity for
agency nurse closed claims is $186,430.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Claim Scenario: Successful Defense of a Nurse
It is CNA’s claim policy to pay covered claims involving actual
Shortly after the nurse performed the triage on the patient,
liability fairly and promptly, while aggressively defending unsub- .
she was relieved for her lunch break. She gave a report to the
stantiated claims. The following claim scenario demonstrates
new nurse on all the patients in the waiting area, advising him
our aggressive defense of a CNA/NSO-insured nurse, which
that the last patient she triaged should be the next patient to
succeeded despite the seriousness of the patient’s injuries,
be taken to an available treatment bed. Thirty minutes later,
including pain, suffering and death.
the CNA-insured nurse arrived back at the triage area and
A registered nurse with 19 years of experience as an emergency
re-evaluated the patient per hospital protocol, noting that the
nurse (including 15 as a certified emergency nurse) was working
patient’s status remained unchanged.
noticed that the patient was still in the waiting area. The nurse
in the triage area of the emergency department. A 34-year-old
female patient was sent to the emergency department from
Ninety minutes after her initial triage, the patient was taken to
the local dialysis clinic to have her hemodialysis catheter, which
the emergency department treatment area. The nurse had no
was bleeding around the insertion area, examined by the emer- .
additional contact with the patient. The patient was examined by
gency department practitioner. The patient was accompanied
the emergency department practitioner and had sutures placed
by her mother and son, who appeared to be about 10 years old.
around the catheter site. She was discharged home moments
The nurse noted in the triage portion of the medical record
after the sutures were completed and told to follow up with the
that the patient appeared ill and disheveled, and she allowed
dialysis clinic the next day.
her mother to answer all the medical questions.
The next morning, the patient was found unresponsive and
During the 15-minute triage process, the nurse noted that the
pronounced dead.
patient’s vital signs were normal, she had plus 2 pitting edema
in her lower extremities and her catheter seemed intact with .
Experts were retained, who determined that the nurse had
a small amount of dried blood, but no active bleeding at the
acted within her scope of practice and in compliance with both
insertion site. On a five-level emergency department triage
the standard of care and hospital policy. Documentation sup-
scale, the nurse rated the patient as a “3-urgent,” meaning that
ported the nurse’s frequent checks of the patient and the reasons
the patient should be seen by a practitioner within 15 to 60
for not triaging the patient at a higher acuity level. The case
minutes following triage. As there were no available beds in the
against the nurse was defended successfully at trial, with the jury
treatment area of the emergency department, the nurse asked
determining that the nurse was not responsible for the patient’s
the patient and her family to take a seat near the triage area
untimely death.
to facilitate monitoring.
The claim took four years and more than $165,000 in expenses
to resolve. While it may have been less expensive to settle the
claim, the nurse’s proper care of the patient and complete
documentation made an aggressive defense not only possible,
but ultimately successful.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
37
Licensed practical/licensed vocational nurse closed claims
The previous charts in the report combine RN and LPN/LVN closed claims data. To help LPNs/LVNs
better understand their unique risk exposures, this section compares the 63 closed claims where
the defendant was an LPN or LVN with the 486 RN closed claims. The top three results for each of
the claim characteristics analyzed are presented in Figure 20, below.
– LPNs/LVNs are defendants in 11.5 percent of the closed nurse claims. The distribution of CNA/
NSO-insured nurses, while fluid, is approximately 11 percent LPNs/LVNs and 89 percent RNs.
– The severity for LPN/LVN closed claims of $157,598 is similar to the severity for RN closed claims
of $165,491.
– The LPN/LVN specialty representing the highest severity is obstetrics, while for RNs the highest
severity specialty is occupational health.
– Treatment/care and medication administration are among the costliest allegations for both RNs
and LPNs/LVNs.
– Permanent total disability had the highest severity for both LPNs/LVNs and RNs.
20 TOP THREE HIGH-SEVERITY CLAIM ELEMENTS FOR RNs AND LPNs/LVNs
(Closed Claims with Paid Indemnity ≥ $10,000)
Professional Designation
RN
LPN/LVN
Percent of closed claims
88.5%
11.5%
$165,491
$157,598
Occupational health
Obstetrics
Neurology
Home care
Obstetrics
Occupational health
Occupational health center
Practitioner’s office
Obstetrics – inpatient .
perinatal services
Patient’s home
Severity
Specialties
Locations
Nurse residence
Allegations
Injuries
Medication administration
Patients’ rights
Monitoring
Treatment and care
Treatment and care
Medication administration
Coma
Fetal/infant birth-related .
brain injury
Neurological deficit/damage
Seizure
Causes of death
Brain injury .
(other than birth-related)
Fetal death
Congestive heart failure
Disabilities
Occupational health center
Cardiopulmonary arrest
Coma
Allergic reaction/anaphylaxis
Cardiopulmonary arrest
Injury resulting from elopement
Permanent total disability
Permanent total disability
Death
Permanent partial disability
Temporary total disability
Death
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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Summary of Closed Claims with a
Minimum Indemnity Payment of $1 Million
The closed claims in Figure 21 resolved with an indemnity payment of $1 million. Note that the
CNA/NSO professional liability insurance indemnity limit is $1 million per claim, although judgments
awarded against a defendant may be higher. The highest-severity closed claims most frequently
involve treatment and care, such as failure to comply with facility policies or operate within the nurse’s
appropriate scope of practice. These actions render the claims difficult to defend.
21 CLOSED CLAIMS WITH PAID INDEMNITY OF $1 MILLION
Summary
Allegation
Injury
Licensure type
Specialty
Location
A nurse caring for a patient in a hotel
room failed to assess patient for dehydration and hypovolemia following
multiple facial procedures.
Assessment
Death
RN
Plastic surgery/
reconstruction
Practitioner’s
office
A nurse failed both to complete a full
assessment and to notice that the
patient was pre-eclamptic.
Assessment
Seizure
RN
Obstetrics – .
prenatal
Hospital – .
obstetrics,
C-section suite
A nurse failed to monitor labs, advocate
for patient and restart heparin according to practitioner order.
Monitoring
Brain injury
other than
birth-related
RN
Neurology
Hospital – .
inpatient surgical
A nurse asked a mother to hold her
child’s head while she left to obtain
tape for the child’s tracheostomy tube.
The child’s tracheostomy tube became
dislodged, and when the nurse returned,
the child was blue and unable to .
re-intubate until 20 minutes later.
Monitoring
Neurological
deficit/damage
RN
Pediatric
Pediatric .
intensive .
care unit
A nurse failed to request a continuous
pulse oximetry monitor for patient after
surgery. The patient was at high risk .
for decreased oxygen levels related to
surgery, increase of hydromorphone and
patient’s self-proclaimed sleep apnea.
Monitoring
Neurological
deficit/damage
RN
Adult medical/
surgical
Hospital – .
inpatient surgical
A nurse failed to initiate policy .
for treatment of non-reassuring .
fetal distress.
Treatment/care
Fetal/infant
birth-related
brain injury
RN
Obstetrics – .
labor and .
delivery
Hospital obstetrics, .
labor and .
delivery
A nurse failed to monitor vital signs
after patient was given high doses of
narcotics while in the PACU.
Monitoring
Death
RN
Adult medical/
surgical
Hospital – .
inpatient surgical
The director of obstetrical nursing
failed to provide proper administrative
and supervisory support when nurse
caring for patient was having difficulty
obtaining practitioner response.
Treatment/care
Loss of limb
RN
Obstetrics – .
postpartum
Hospital – .
obstetrics, .
postpartum care
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
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21 CLOSED CLAIMS WITH PAID INDEMNITY OF $1 MILLION (CONTINUED)
Summary
Allegation
Injury
Licensure type
Specialty
Location
A claim was filed against a nurse in .
her role as manager of patient care.
The patient was left in deplorable .
conditions at home and was not .
given seizure medication. In addition,
the patient’s pressure ulcer was left
untreated, leading to sepsis.
Abuse/ .
patients’ rights
Seizure/sepsis
RN
Home health
Patient’s home
A claim was filed against director .
of nursing in her role as supervisor .
of patient care. A patient given a .
narcotic to keep him quiet, later .
died of overdose.
Abuse/ .
patients’ rights
Death
RN
Home health
Patient’s home
A labor and delivery unit nurse .
identified fetal distress on the fetal .
heart monitor, but did not timely
report concerns to practitioner.
Treatment/care
Fetal/infant
birth-related
brain injury
RN
Obstetrics – .
labor and .
delivery
Hospital obstetrics, .
labor and .
delivery
The nurse gave undiluted hydro- .
morphone in three minutes .
by intravenous push instead of .
intravenously over several hours.
Medical .
administration
Coma
RN
Emergency and
urgent care
Hospital – .
emergency
department
A labor and delivery unit nurse .
failed to identify fetal distress on .
the fetal heart monitor.
Diagnosis
Fetal/infant
birth-related
brain injury
RN
Obstetrics – .
labor and .
delivery
Hospital obstetrics, .
labor and .
delivery
A nurse working in an obstetrics/ .
gynecology office communicated .
a message to practitioner that a
patient was having problems, but
failed to explain that the problems
were emergent.
Treatment/care
Fetal/infant
birth-related
brain injury
LPN/LVN
Obstetrics – .
prenatal
Practitioner’s
office
A nurse failed to initiate the chain of .
command when practitioner would not
respond to her concerns of identified
non-reassuring fetal distress.
Treatment/care
Fetal/infant
birth-related
brain injury
RN
Obstetrics – .
labor and .
delivery
Hospital obstetrics, .
labor and .
delivery
The highest-severity closed claims most frequently
involve treatment and care, such as failure to
comply with facility policies or operate within the
nurse’s appropriate scope of practice.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
40
Risk Control Recommendations
The following risk control recommendations are designed to serve as a starting point for nurses
seeking to assess and enhance their patient safety risk control practices:
Patient safety
Falls are a common yet largely avoidable source of both patient harm and litigation. While eliminating
falls may not be a realistic goal, decreasing falls and mitigating the severity of fall-related injuries
should remain a top priority for nurses in any healthcare setting. Fall-related injuries include head
trauma, broken bones and death, with losses ranging into six figures. Over half of the falls in the
dataset occurred in either the patient’s home or an aging services facility, when an unattended patient
failed to comply with caregiver instructions, attempted to self-transfer or self-ambulate, rejected
assistance from staff or maneuvered into a wheelchair without assistance.
Nurses can help minimize falls and fall-related liability by following sound operational policies,
environmental precautions and documentation practices, especially with respect to describing
the patient’s condition and the specific circumstances of the fall. The following suggested actions
can assist in reducing the liability associated with patient falls:
– Focus fall prevention programs and care plans on the locations of greatest risk, such as bedside,
bathrooms and hallways.
– Encourage teamwork in the care-planning process. Include certified nursing assistants in order
to benefit from their unique knowledge of patients and families.
– Assess the environment for potential hazards, make patients and families aware of any dangers
and encourage environmental modifications, as necessary.
– Educate patients and families about fall-related risks and preventive measures. Encourage
patients and families to mitigate fall risks by addressing such issues as hydration, medication
management and environmental safety.
The following organizational and agency websites provide a wide range of information on fall .
prevention and gerontological health:
– American Academy of Family Physicians at www.aafp.org.
– American Geriatrics Society at www.americangeriatrics.org.
– Centers for Disease Control and Prevention (CDC), fall prevention information for older adults,
at http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html.
– Fall Prevention Center of Excellence at www.stopfalls.org.
– National Council on Aging at www.ncoa.org.
– National Institute on Aging, one of the National Institutes of Health, at www.nia.nih.gov.
– American Physical Therapy Association at www.apta.org/BalanceFalls/.
PART 1   CNA AND NSO Nurse 2015 Claim Report Update
41
Medication safety has become a more prominent issue in recent years, as national patient safety
initiatives have focused practitioners’ attention on the need to improve medication management and
error reporting processes. However, dispensing and administration lapses, which are often difficult
to defend in the event of a malpractice claim, continue to occur. By following the suggested actions,
nurses can assist in reducing the liability associated with medication errors:
– Follow established medication protocols. If “work-arounds” persist, consult with the facility’s
nursing leadership about methods to enhance staff monitoring and compliance.
– Understand that while bar-coding scanning of the patient’s armband to confirm identity can
reduce medication errors, this method is not foolproof. Consistently use the “six rights” when
administering medications to patients:
– Right patient
– Right drug
– Right dose
– Right route
– Right time
– Right documentation
– Know the medication(s) being administered to the patient. While nurses do not prescribe and
only rarely dispense medications, they are responsible for administering drugs. Therefore they
must understand why the patient is taking a particular medication as well as interactions, side
effects or adverse reactions that may occur.
Environmental safety is another major area of concern, especially as home-based medical care
continues to expand. Whether in an acute care facility or their own home, patients have the right to
receive care in a safe environment. For this reason, nurses must be cognizant of patients’ surround- .
ings and know how to keep them out of harm’s way.
Assessment and monitoring
Accurate and timely assessment of patients and careful monitoring can mean the difference between
a favorable and unfavorable outcome. The following strategies can help nurses im…
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