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PHILADELPHIA -- Doctors who supervise physician assistants (PAs) and nurse practitioners (NPs) should be aware that they themselves could be sued if their supervisee is involved in an adverse outcome, a researcher said Monday at the annual meeting of the American College of Emergency Physicians.

"Physicians may underestimate their risk of liability when supervising NPs and PAs," said Summer Ghaith, JD, a medical student at the Mayo Clinic Alix School of Medicine in Scottsdale, Arizona. "A recent study showed that about 80% of lawsuits against nurse practitioners specifically also named the supervising physician."

Currently, 27 states do not require supervision of NPs, while PAs are a little bit further behind on gaining independence, with only two states not requiring supervision for them, Ghaith said. "With current and emergent laws expanding the scope of NPs and PAs, it is important for us to understand where the highest risk of medical error lies."

To that end, Ghaith and Rachel Lindor, MD, JD, also of the Mayo Clinic, set about providing a descriptive review of NP and PA involvement in medical malpractice lawsuits. To do that, they searched the Thomson Reuters Westlaw database for jury verdicts and settlements from 1985 to 2020 that contained the words "malpractice" and either "physician assistant" or "nurse practitioner." The researchers excluded certain types of cases, including those involving expert witness disputes, contract issues, worker compensation claims, "standard of care" issues, and licensure issues.

A total of 1,048 cases met the search criteria initially, but after exclusions they ended up with 144 cases, 99 involving a PA and 49 involving an NP (a few cases involved both). Cases occurred in 32 different states, with California and Massachusetts being the most frequent locations. The median age of the patient was 31.5 years, and the median time to resolve the cases was 5 years. Primary care was the specialty most often involved (50 cases) followed by emergency medicine (24 cases) and surgical specialties (22 cases). In 35 of the cases, patients were given prescriptions, of which eight were for controlled substances.

Nearly two-thirds of the cases (63.9%) were for failure to diagnose, followed by procedural errors (11.8%) and failure to treat (11.1%). Medication or test errors accounted for 7.6% of cases. Patient outcomes included permanent disability in 42.4% of cases, death in 38.2%, and temporary disability in 12.5%.

The supervising physician was named in 96 cases; in another 15 cases, it was unclear whether the physician was named. The physician saw the patient in five cases and heard about the patient during the patient's visit in 17 cases; the physician's involvement was unclear in 51 cases, and in 71 cases the physician was not involved in the visit that led to the lawsuit.

Looking at the legal outcomes, "37.5% found no liability on behalf of the physician, while 27.8% resulted in settlement, 25.7% found negligence on behalf of the physician, and 9% are unknown outcome," Ghaith said. In terms of monetary penalties, of the cases where negligence was found, "the mean award was about $3.2 million, compared to $1.6 million if the physician settled."

Overall, "this review just highlights the types of situations in which NPs or PAs involved in patient care led to a lawsuit, with errors in diagnosis emerging as the most common category in our series of cases," Ghaith said. "Physicians are named in most of these cases, although they actually saw or heard about the patient in the minority of cases. This underscores the liability risks for physicians while supervising non-physician providers, and overall understanding of these risks is really important as the scope [of practice] of these NPs and PAs continues to increase, so we can determine optimal practice patterns moving forward."

This story has been updated to clarify physician involvement in the cases studied.

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