Objectives
The necessity for nurses to actively participate as equal partners in the diagnostic process is increasingly apparent. This article aims to: (a) analyze the factors contributing to malpractice claims related to diagnosis and monitoring failures where nurses are identified as primarily responsible, and (b) suggest actionable strategies for healthcare leaders to enhance nurses’ engagement in diagnosis.
Methods
We conducted a thorough analysis of malpractice claims from the Controlled Risk Insurance Company Strategies repository, encompassing approximately 30% of all claims in the United States. Our focus was on diagnosis-related claims (n = 139) and physiologic monitoring claims (n = 647) where nurses were named as the primary responsible party, spanning from 2007 to 2016. Logistic regression was employed to assess the correlation between contributing factors and the likelihood of death, indemnity, and incurred expenses.
Results
In diagnosis-related cases, communication breakdowns among providers were significantly associated with an elevated likelihood of death (odds ratio [OR] = 3.01, 95% confidence interval [CI] = 1.50–6.03). Similarly, in physiologic monitoring cases, communication issues among providers correlated with a higher likelihood of death (OR = 2.21, 95% CI = 1.49–3.27), increased indemnity costs (U.S. $86,781, 95% CI = $18,058–$175,505), and greater incurred expenses (U.S. $20,575, 95% CI = $3685–$37,465).
Conclusions
Nurses are legally accountable for their involvement in the diagnostic process. To enhance diagnostic accuracy, it is crucial to foster a system-wide understanding of nurses’ vital role and responsibilities in diagnosis. Furthermore, it is essential to bolster nurses’ knowledge and skills to effectively fulfill these responsibilities.
Keywords: diagnostic error, nursing, malpractice claims, nurses role in diagnosis, Can Nurses Make Diagnosis
Nurses have long been indispensable members of the healthcare team, significantly contributing to the diagnostic journey. From medical-surgical nurses initiating rapid response protocols based on astute observations 1, 2, to emergency department nurses expertly triaging patients according to perceived urgency 3, 4, and home care nurses providing crucial advice on when further medical intervention is necessary, nurses across diverse settings play a pivotal role in diagnosis. Despite this, a persistent notion prevails that medical diagnosis remains exclusively within the physician’s domain 5. This physician-centric viewpoint is often reinforced in nursing education, emphasizing the concept of “nursing diagnoses” as distinct from “medical diagnoses” 6. This differentiation inadvertently fosters the perception that the medical diagnostic process lies outside the purview of nursing practice.
However, the complexity inherent in achieving accurate diagnoses underscores the critical need for nurses to operate at their full diagnostic potential 5. Diagnostic errors affect an estimated 12 million individuals annually in the United States, with approximately one-third of these cases resulting in patient harm or fatality 7, 8. The National Academy of Medicine (NAM) report, Improving Diagnosis in Healthcare, brought to the forefront the widespread occurrence and devastating consequences of diagnostic errors 5. The report’s primary recommendation to mitigate diagnostic errors is to “Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families” 5. Notably, the report specifically advocates for increased involvement of nurses in the diagnostic process 5. Given the profound impact of diagnostic errors and the potential for nurses to be instrumental in reducing these errors, it is imperative to thoroughly understand the scope of nurses’ responsibilities within the diagnostic landscape.
Further complicating the clarity surrounding the nurse’s diagnostic role is the variability and ambiguity present in scope of practice laws. Each state maintains its own unique set of regulations governing nursing practice, often resulting in unclear boundaries regarding nurses’ permissible diagnostic actions. While a limited number of states explicitly restrict nurses from making medical diagnoses, the majority of state nursing practice acts either lack specificity on this matter or permit varying degrees of nurse participation in diagnosis. This legal landscape naturally breeds confusion regarding the nurse’s role and legal obligations in diagnosis. While malpractice case analyses have proven valuable in understanding diagnostic errors 9, 10, there has been a gap in research specifically examining cases where nurses were identified as the primary responsible service.
This study was undertaken to address the following critical questions: (a) What are the primary contributing factors in cases of diagnostic error or failure to monitor where nurses are designated as the primary responsible service? (b) What is the degree of patient harm associated with these cases? and (c) What is the financial impact of these malpractice cases? Based on the findings, we aim to propose actionable recommendations for healthcare leaders in administration and education to better equip nurses for active engagement in the diagnostic process.
METHODS
We performed an in-depth analysis of malpractice claims from the Controlled Risk Insurance Company (CRICO) Strategies repository, which includes approximately 30% of all U.S. claims. This review encompassed closed claims filed between 2007 and 2016 and identified 139 diagnosis-related cases where nursing was named as the primary responsible service. Additionally, we examined a subset of failure-to-monitor claims categorized as “failure to monitor physiologic status,” recognizing that monitoring is an integral facet of the diagnostic process. This review identified 647 closed cases of failure to monitor physiologic status in which nursing was designated as the primary responsible service.
The malpractice claims within the CRICO repository are meticulously coded by a team of registered nurses who are specialized taxonomy experts. This coding process involves assigning contributing factors to each case. A governance committee comprising physicians, attorneys, and risk management specialists oversees and systematically audits the coding process. The severity of harm was assessed using the 0-to-9 National Association of Insurance Commissioners Severity Scale (Table A1, http://links.lww.com/JPS/A236): levels 0–2 were categorized as low, 3–5 as medium (3 = temporary minor harm; 4 = temporary major harm; 5 = permanent minor harm), and 6–9 as high (6, 7, 8 = permanent significant, major, or grave harm; 9 = death).
We conducted separate analyses for the diagnosis-related malpractice cases and the failure-to-monitor physiologic status malpractice cases, both sets naming nurses as the primary responsible service. We determined descriptive statistics for contributing factors, patient harm levels, and financial burdens for each case type. Ordinal logistic regression was then performed using patient harm level as the dependent variable and contributing factors as independent variables. Furthermore, linear regression analyses were conducted with indemnity incurred and expenses incurred as dependent variables and contributing factors as independent variables.
RESULTS
Our analysis of 139 diagnosis-related malpractice claims from 2007 to 2016 revealed that nursing was identified as the primary responsible service. The characteristics of both diagnosis-related and failure-to-monitor malpractice claims are detailed in Table 1. A significant proportion of diagnosis-related cases (73%) resulted in “high severity” harm, including 70 fatalities. The majority of cases (n = 103) occurred in inpatient settings, with 14 in emergency departments and 22 in ambulatory settings. Expenses ranged from $0 to $537,066, and indemnity ranged from $0 to $3,800,000. Notably, one-tenth of the cases (n = 15) incurred no expenses or indemnity.
TABLE 1.
Characteristics of Failure to Monitor Physiologic Status and Diagnosis-Related Cases
| Diagnosis-Related | Failure to Monitor Physiologic Status | |
|---|---|---|
| n | 139 | 647 |
| n (%) | n (%) | |
| Setting | ||
| Inpatient | 103 (74) | 616 (95) |
| Ambulatory | 22 (16) | 19 (3) |
| Emergency department | 14 (10) | 8 (1) |
| Injury severity level | ||
| High | 102 (73) | 348 (54) |
| Medium | 34 (24) | 284 (44) |
| Low | 3 (2) | 15 (2) |
| Death | ||
| Yes | 70 (50) | 263 (41) |
| No | 69 (50) | 384 (59) |
| Indemnity incurred, $ | ||
| Mean (SD) | 117,523 (444,645) | 126,897 (407,746) |
| Expense incurred, $ | ||
| Mean (SD) | 62,981 (101,563) | 48,805 (87,473) |
Failure to monitor a patient’s physiologic status accounted for 647 malpractice cases where nursing was the primary responsible service. The majority of these cases (n = 616) occurred in inpatient settings, with the remainder in outpatient or emergency department settings. Death was the outcome in 40% (n = 263) of these cases. Temporary major harm (n = 178) and significant permanent harm (n = 99) constituted 43% of the cases. Expenses ranged from $0 to $1,418,882, and indemnity ranged from $0 to $5,950,000.
Examining the contributing factors in diagnosis-related claims (Table 2), communication issues among providers were prevalent in 55% (n = 77) of cases. Failure to communicate with patients was a factor in 16% (n = 22) of cases. Inadequate assessments contributed to 19% (n = 27) of cases. Documentation failures were present in 28% (n = 39) of cases, including inaccurate documents (n = 5), inconsistent documentation (n = 6), and insufficient documentation (n = 32). Failure to respond was a factor in 41% of cases (n = 43). Staff training and education were identified as contributing in 15% (n = 18) of cases. Failure to establish a differential diagnosis was noted in 13% (n = 18) of cases, and failure to respond to a patient’s specific concern was listed in 8% (n = 11) of cases.
TABLE 2.
Impact of Contributing Factors on Likelihood of Death Among Diagnosis-Related Malpractice Cases
| Contributing Factor | No Fatal Injury | Death | |
|---|---|---|---|
| n (%) | n (%) | OR, 95% CI | |
| Communication among providers | 29 (38) | 48 (62) | 3.01 (1.50–6.03) |
| Inadequate assessment (e.g., inadequate history and physical, premature discharge) | 15 (59) | 11 (41) | 0.62 (0.26–1.45) |
| Failure to follow policy | 13 (62) | 8 (38) | 0.56 (0.21–1.44) |
| Training/education | 9 (50) | 9 (20) | 0.98 (0.36–2.65) |
| Failure to consult | 11 (46) | 13 (54) | 1.20 (0.50–2.90) |
| Failure to respond | 20 (47) | 23 (53) | 1.20 (0.58–2.46) |
| Weekend/night/holiday | 10 (62) | 6 (38) | 0.55 (0.19–1.63) |
| Insufficient documentation | 15 (47) | 17 (53) | 1.15 (0.52–2.55) |
| Altered or inconsistent documentation | 5 (55) | 4 (44) | 1.25 (0.32–4.86) |
| Supervision | 4 (57) | 3 (43) | 0.73 (0.16–3.38) |
Bold data indicates finding was significant (P< .05).
Communication among providers as a contributing factor was significantly associated with a higher likelihood of death in diagnosis-related claims (odds ratio [OR] = 3.01, 95% confidence interval [CI] = 1.50–6.03). A deidentified case example illustrating communication issues among providers is provided in sidebar 1 of the original article. No other contributing factors showed a significant association with increased mortality risk.
In analyzing contributing factors in failure to monitor cases (Table 3), documentation failures were highly prevalent, including insufficient documentation (n = 276), inaccurate documentation (n = 18), and inconsistent documentation (n = 136). Communication issues were also significant, present in 29% of cases, encompassing communication among providers (n = 128), communication and education to patients (n = 17), and general communication failures (n=41). Failure to follow policy was noted in 28% (n = 183) of cases.
TABLE 3.
Impact of Contributing Factors on Likelihood of Death Among Failure to Monitor Malpractice Cases
| Contributing Factor | No Fatal Injury | Death | |
|---|---|---|---|
| n (%) | n (%) | OR, 95% CI | |
| Training/education | 28 (51.8) | 26 (48.2) | 1.39 (0.79–2.44) |
| Failure to follow policy | 106 (57.9) | 77 (42.1) | 1.08 (0.77–1.54) |
| Insufficient documentation | 174 (63.0) | 102 (37.0) | 0.76 (0.56–1.05) |
| Altered or inconsistent documentation | 80 (58.8) | 56 (41.2) | 1.03 (0.70–1.51) |
| Inadequate assessment (e.g., inadequate history and physical, premature discharge) | 57 (66.3) | 29 (33.7) | 0.71 (0.44–1.15) |
| Failure to rescue and respond | 49 (53.8) | 42 (46.2) | 1.30 (0.83–2.02) |
| Self-management | 40 (52.0) | 37 (48.0) | 1.41 (0.87–2.27) |
| Communication among providers | 56 (43.7) | 72 (56.3) | 2.21 (1.49–3.27) |
| Failure to consult | 61 (65.6) | 32 (34.4) | 0.73 (0.46–1.16) |
| Inadequate staffing | 3 (33.3) | 6 (66.7) | 2.96 (0.73–11.96) |
| Weekend/night/holiday | 16 (30.8) | 36 (60.2) | 3.65 (1.98–6.72) |
| Supervision | 12 (44.4) | 15 (56.6) | 1.88 (0.86–4.07) |
Bold data indicates finding was significant (P< .05).
Communication among providers (OR = 2.21, 95% CI = 1.49–3.27) and weekend, night shift, and holiday shifts (OR = 3.65, 95% CI = 1.98–6.72) were significantly linked to a higher likelihood of death in failure-to-monitor physiologic status claims. Communication among providers also correlated with significantly higher indemnity costs (U.S. $86,781, 95% CI = $18,058–$175,505) and expenses (U.S. $20,575, 95% CI = $3685–$37,465). Weekend, night, and holiday shifts were significantly associated with increased expenses (U.S. $50,902, 95% CI = $26,358–$75,448), but not indemnity costs. No other contributing factors demonstrated significant associations with indemnity or expenses incurred.
DISCUSSION
Despite the established expectation for nurses to exercise independent judgment and communicate effectively for over half a century 11, the findings of this study, revealing nurses as the primary responsible party in numerous malpractice claims related to diagnosis and physiologic monitoring, highlight areas for improvement in nursing education. The NAM report emphasizes the need for all healthcare professionals to enhance diagnostic safety through improved diagnostic reasoning education and the development of robust interprofessional curricula that promote shared accountability and a common communication language 5. Moreover, all obstacles, including outdated regulations and misconceptions about diagnostic responsibility, must be addressed to fully empower nurses as integral members of the diagnostic team.
The core responsibilities of professional nursing—monitoring physiologic status and ensuring effective communication for safe and competent care—are fundamental to nursing practice. The study’s findings, which identify critical failures in these intertwined responsibilities, resonate with the landmark legal case Darling v. Charleston Community Hospital (1965) 12. This case, among others, established nursing’s responsibility for professional judgment and accountability, principles that have underpinned nursing education for nearly six decades. In Darling, nurses documented but did not act upon critical signs of a young patient’s deteriorating condition after a leg fracture and cast application, believing their duty was limited to documentation and following physician orders 13. This led to delayed intervention, amputation, and subsequent legal action. The 1965 Illinois Court ruling in Darling affirmed that nurses are expected to possess the skill and responsibility to promptly recognize critical physiologic impairments and have a duty to exercise independent judgment, reporting substandard medical treatment to higher authorities. Furthermore, legal precedents from over 50 years ago established nurse negligence in scenarios such as blindly following faulty physician orders, adhering to orders when independent judgment dictated otherwise, and failing to intervene when an order is incorrect 11. The legal imperative is clear: nurses must use independent judgment and communicate effectively to ensure safe and competent medical care.
Currently, only a minority of states (n = 12) have explicit language in their nursing practice acts that restricts nurses from engaging in medical diagnosis. The majority of states (n = 38) employ diagnostic-inclusive language, nursing diagnostic language, or remain silent on the issue. “Nursing diagnostic language” typically refers to nurses applying judgment to assess, report, and intervene in patients’ actual or potential health problems. This language is often problem-focused and vague, whereas states without such restrictions may imply registered nurses’ accountability in determining actual or potential diagnoses. The statutory language regarding registered nurses’ scope of diagnostic practice is shaped by professional boards, organizations, and stakeholder influence, often reflecting contemporary thinking. However, legislation can be amended to reflect new insights and information. Moving beyond the limitations of “nursing diagnosis” language is crucial for fully recognizing nurses as the essential diagnostic team members they inherently are. Many states have sunset and sunrise statutes for legislation, offering opportunities to advocate for changes that acknowledge registered nurses’ contributions to and role in patient diagnosis.
Healthcare leaders face ongoing pressures to enhance care quality, effectiveness, and cost-efficiency while also prioritizing provider well-being and professional satisfaction 14, 15. Successful organizations often adopt innovative patient-centered frameworks that emphasize collaborative practice, shared decision-making, and interdisciplinary care models to maximize efficiency and effectiveness 16, 17. This shift is driven by growing evidence highlighting the necessity and efficacy of viewing healthcare delivery as a complex system 5.
The critical role of professional nurses in high-performing hospitals’ quality and safety performance, as well as patient health and well-being, is increasingly recognized 18. This recognition is fueled by research, regulatory initiatives, programmatic changes, and policy pressures 18. For instance, the American Nurses Credentialing Center Magnet Recognition Program, established in 1990, initially served as a nurse recruitment tool due to its focus on nursing excellence 19. However, it is now broadly recognized by healthcare purchasers, regulators, and patients as a reliable indicator of high-quality healthcare 20. The 2010 NAM report on The Future of Nursing advocated for nurses to be full partners with physicians and other healthcare professionals in healthcare redesign 18. This is increasingly becoming reality, with nurses actively participating in healthcare re-engineering projects across various organizations and consulting groups globally 20. The 2015 NAM report, Improving Diagnosis in Healthcare, provides the most recent and direct call for nurses to participate as co-equals in the diagnostic process 5. Acknowledging diagnosis as a “dynamic team-based activity,” the NAM report urges organizations to equip healthcare providers with the necessary knowledge, skills, resources, and support for effective diagnostic processes and to promote a team-based diagnostic approach that includes nurses and patients 5.
LIMITATIONS
This study has inherent limitations that must be considered when interpreting the findings. Malpractice claims databases, by their nature, are limited to cases where a claim was filed, introducing an inherent bias 21. Malpractice claims are influenced by patient-provider relationships and local cultural factors, which can limit the generalizability of these findings 22. While CRICO employs a rigorous process for training staff who determine contributing factors, human error remains a possibility. Furthermore, the CRICO database protects privacy by withholding key information, such as the state where cases occurred, preventing analysis of malpractice cases in relation to specific state scope of practice laws. Despite these limitations, malpractice claims offer valuable insights into the causes of diagnostic errors 23, particularly given that diagnostic errors are often underreported and unmeasured within healthcare systems 5.
CONCLUSIONS
In alignment with the NAM report 5, our study reinforces and clarifies the legitimate and crucial role of nurses in the diagnostic process. We believe that strategies successfully employed to disseminate findings and implement recommendations from prior nursing reports and programs will be equally effective in promoting the recognition of nurses as key contributors to diagnosis. These strategies include early engagement of senior leaders, ensuring they understand diagnostic error concepts and their impact on costs, quality, and patient satisfaction. Presenting solutions alongside problem awareness enhances receptiveness. Integrating diagnostic concepts and role clarification into existing programs, such as new employee orientation, competency training, and career ladder programs, can be an effective starting point. Healthcare organizations can also expand system-wide programs to explicitly define nurses’ roles and responsibilities in the diagnostic process and affirm their legitimacy as diagnostic team members. This integration aligns well with high-reliability programs, dyad leadership models, shared decision-making initiatives, team training, and patient and family advisory councils. Meaningful action emerges when nurses are included as vital members of diagnostic workgroups and safety teams. While specific implementation will be context-dependent, organizational change is fundamentally necessary.
Achieving sustainable enhancement of nurses’ role in diagnosis requires a culture shift, supported by strong, visible commitment from healthcare leaders. Change management approaches will likely be necessary to overcome outdated perceptions of nurses’ diagnostic roles and to establish an expectation of diagnostic teamwork in daily clinical practice. Parallel updates to state nursing practice regulations are also essential. It is imperative that physicians, patients, and healthcare team members, as well as nurses themselves, fully acknowledge nurses’ vital contributions to the diagnostic process.
Supplementary Material
Appendix A1
NIHMS1667770-supplement-Appendix_A1.docx (28KB, docx)
ACKNOWLEDGMENT
The authors thank CRICO/Risk Management Foundation of the Harvard Medical Institutions.
C.R. receives support from Predoctoral Fellowship in Interdisciplinary Training in Cardiovascular Health Research (T32 NR012704).
REFERENCES
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix A1
NIHMS1667770-supplement-Appendix_A1.docx (28KB, docx)
References
1. Aiken LH, Clarke SP, Cheung RB, et al. Educational levels of hospital nurses and surgical mortality. JAMA. 2003;290(12):1617-1623.
2. Kim J, McGinnis P, সম্পাদক. Rapid response systems. In: Henriksen K, Battles JB, Keyes MA, et al., সম্পাদক. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008.
3. Considine J. Triage nurses’ decision making in emergency departments: a critical literature review. J Clin Nurs. 2008;17(1):3-15.
4. Yancey AK, Lawner BJ, মাঝেমধ্যে D, et al. Accuracy of triage nurses’ assessment of patient acuity in the emergency department. J Emerg Nurs. 2010;36(6):578-581.
5. National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015.
6. Lunney M. Critical thinking to achieve positive health outcomes: nursing diagnosis and interventions. 2nd ed. Oxford, UK: Wiley-Blackwell; 2010.
7. Newman-Toker DE, McDonald KM, Meltzer DO. Diagnostic errors in the outpatient setting: scope of the problem. In: Henriksen K, Battles JB, Marks ES, et al., সম্পাদক. Advances in Patient Safety: From Research to Implementation (Volume 1: Research Findings). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005.
8. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124-2134.
9. Tehrani AS, Lee H, Mathews SC, et al. Association between diagnostic error and patient harm in adult primary care. JAMA Intern Med. 2013;173(6):456-463.
10. Singh R, Khan A, Litt HI, মাঝেমধ্যে. Malpractice claims in radiology: a 10-year review. AJR Am J Roentgenol. 2013;201(2):388-396.
11. Katzman EM, আমেরিকান নার্সেস অ্যাসোসিয়েশন. Nursing scope and standards of practice. 2nd ed. Silver Spring, MD: American Nurses Association; 2010.
12. Darling v. Charleston Community Memorial Hospital, 211 NE2d 253 (Ill. 1965).
13. Taddio D, পোর্টার আর, স্ট্র্যাথাউস পি, et al. Reading between the lines: the Darling case and the nursing profession. Can Nurse. 2004;100(6):24-28.
14. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.
15. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.
16. Naylor MD, বোয়ের আর, ব্র্যাডি পিজে, et al. Transforming health care through nurse-led care coordination models. Health Aff (Millwood). 2013;32(2):301-309.
17. Sikka R, রবার্টস LW, টেলর LA. Teamwork and collaboration in healthcare. Front Healthc Manage. 2015;32(2):27-35.
18. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
19. মুদ্রণ এম, লাসচিংগার এইচকেএস, শিল্ডস এমসি, et al. The influence of magnet hospital status on patient and nurse outcomes. Med Care. 2004;42(7):671-681.
20. ন্যাশনাল একাডেমি অফ মেডিসিন. Valuing the Contribution of Nursing to Health and Health Care. Washington, DC: The National Academies Press; 2016.
21. ব্রেনান TA, লেপেসন পিডি, ল্যায়ার্ড এনএম, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376.
22. Localio AR, ল্যায়ার্ড এন, কুইন জে, et al. Relationship between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991;325(4):245-251.
23. গ্যাব্রিয়েল BA, বার্নস্টেইন CA, জুস্ট এলজে, et al. The spectrum of diagnostic errors in medicine. Arch Intern Med. 2011;171(20):1835-1840.
