Late one afternoon in a busy urgent care center, a patient arrived complaining of the worst headache of their life. The patient had fallen and had vomited once. The differential diagnosis prepared by the nurse practitioner (NP) considered concussion first, then migraine. The NP ordered blood work, but the patient’s elevated white blood count (WBC) was not available to the NP prior to discharge. The patient returned to the clinic twice with worsening symptoms and was examined by other practitioners. When the patient’s WBC finally came to light, the patient was admitted for a stat MRI and neurology consult—but the patient died of bacterial meningitis.
Without the elevated WBC, this patient’s story was not complete. Between that missing test result and the red herring of the patient’s fall, it’s alarmingly easy to understand how this misdiagnosis occurred. The NP may have fallen prey to the assumption that the obvious thing was the only thing: The patient may in fact have had a concussion.
Still, a key question to ask was: Why did the patient fall? As a result of the misdiagnosis, the NP faced potential liability.
Why Do NPs Need Their Own Liability Insurance?
NPs are often underinsured. NPs’ mental model of their liability risks may be inadequate: NPs can practice independently in 28 states and in Washington, D.C. They face many of the same risks as physicians—yet are often not as well insured. When NPs are employed, their employers’ coverage may miss NPs’ risks, or coverage limits may be too low, because the dollar amounts of medical malpractice jury awards keep climbing.
Crucially, no deviation from the standard of care is needed for an allegation of malpractice to be made. Here’s a real-life example of NPs’ legal risks:
An NP’s liability nightmare
An NP and a physician partnered to deliver home-health geriatric care through their own business. One of the NP’s patients in a convalescent home had a complex health picture, including dementia. The NP was treating the patient for a urinary tract infection (UTI) when the patient died. The late patient’s spouse filed a board complaint against the NP’s partner physician. A case against the NP by the state’s Board of Registered Nursing followed.
Malpractice insurance covered the physician, but it didn’t cover a board complaint against the NP. Just prior to this incident, the NP had discontinued insurance coverage that would have covered a nursing board investigation, because the NP had supposed that any board complaints would be covered by the policies of the institutions where the NP provided care. Unfortunately, this was not the case. Despite the partner physician writing letters to the Board of Registered Nursing stating that the patient’s death was unrelated to the NP’s care, the board persisted.
Years passed, and due to the lack of insurance coverage, the NP was forced to take out a second mortgage to pay mounting legal fees.
This story perfectly illustrates why NPs need to carry their own medical malpractice coverage.
What Gaps Are Common in Employers’ Liability Coverage for NPs?
Board complaints are one common gap in employers’ coverage. A single board complaint can take several years and tens of thousands of dollars to resolve—and a board complaint places an NP’s license at risk.
Considering financial risks, NPs should scrutinize their employment contracts, looking for individual vs. shared limits of liability. For instance, the contract’s stated monetary limits might apply to the NP, to the NP and a partner physician, to the NP and the employer, etc. NPs should be aware that shared limits increase risks.
What’s the Difference Between the Two Main Types of Policies?
Considering time—when events occur, and when coverage begins and ends—can clarify liability insurance options. Types of policies include:
Occurrence coverage: This policy pays claims for medical acts that occurred while insured. Say you care for a patient in 2024. In 2025, you change jobs and insurance carriers. In 2026, the patient files a claim of malpractice. You’re still covered by your original occurrence policy.
Claims-made coverage: This type of insurance covers claims brought while insured. It is often paired with tail coverage and/or nose coverage.
What Are “Tail Coverage” and “Nose Coverage”?
Tail coverage: Tail coverage attaches to a claims-made policy and, in a sense, extends it. Tail coverage provides coverage for claims brought regarding incidents that occurred while the policy was in effect—but reported later.
Nose coverage: The opposite of tail coverage, nose coverage covers some time period in advance of the start of a claims-made policy.
What Documentation Strategies Are Protective for NPs?
When feeling puzzled during a patient’s visit, take a breath and ask them to start from the beginning. The patient’s narrative is critical—not just for you, but for practitioners to follow.
Stick with SOAP notes
Completing a very thorough narrative does not mean writing volumes. Clinicians are trained in how to document a very thorough SOAP note, and through maintaining this habit, we protect the patient and ourselves. Failing to document the care story is not just a failure of relationship building, but an omission that can turn the course of diagnosis and treatment, increasing risks for all.
Avoid leaping to conclusions, leaving gaps
Time pressure can push clinicians to narrow their diagnostic focus too soon. Keeping our minds open to more possibilities may feel like it’s going to slow us down, but in fact, the opposite is true. Start by mentally “throwing spaghetti at the wall,” stay open to anything that sticks, and capture the patient’s lived experience. Failing to complete the right exam can impact assessment and care planning. This will increase the patient’s risks, and then when medical records leave holes in the patient’s narrative or the clinician’s thought process, that can increase practitioners’ risks. Ask: How can I capture what I am doing with the patient?
Attend to challenging patients
Ensure that patients understand what plan of care is being recommended and why. Keep patients close—and challenging patients closer. Make sure that they feel heard and that the care that is being delivered is standard in the community.
Liability Insurance Offers Peace of Mind While You Provide Care
Liability insurance is not magic: It does not prevent bad things from happening. But medical malpractice coverage is the net under you while you balance on the high wire of delivering care. It protects your license and your career, defends your livelihood and your reputation. It gives you peace of mind while you pursue the work you love.
About TDC Group and Advanced Practice Clinician Coverage
Owned by healthcare professionals for over 45 years, TDC Group is the nation’s largest and most trusted provider of insurance and risk management solutions. Through medical professional liability insurance carrier The Doctors Company, TDC Group provides affordable, top-tier malpractice coverage specifically tailored for advanced practice clinicians. This includes primary, excess, occurrence, and claims-made coverage available for nurse practitioners, certified registered nurse anesthetists, physician assistants, certified nurse midwives, and certified midwives.
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Surani Hayre-Kwan
Surani Hayre-Kwan, DNP, MBA, FNP-BC, FACHE, FAANP is Vice President, Professional Practice and Ambulatory Patient Care, of Sutter Health; and a Member of the TDC Group APC Advisory Board.
Owned by healthcare professionals for over 45 years, TDC Group is the nation’s largest and most trusted provider of insurance and risk management solutions. Through medical professional liability insurance carrier The Doctors Company, TDC Group provides affordable, top-tier malpractice coverage specifically tailored for advanced practice clinicians. This includes primary, excess, occurrence, and claims-made coverage available for nurse practitioners, certified registered nurse anesthetists, physician assistants, certified nurse midwives, and certified midwives.
