Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in. 
Which of the following examples presents a potential medical malpractice scenario? 

A. A 25-year-old who is being treated for acute otitis media reports penicillin allergy to the health care provider. An amoxicillin prescription is advised. The patient takes the amoxicillin without adverse reaction. 

B. A 40-year-old with acute bacterial rhinosinusitis reports to his healthcare provider that his symptoms have not improved after two days of taking a dose-appropriate prescription for amox with clavulanate.  

C. Before taking a medication, a 28-year-old realizes the wrong drug was dispensed by the pharmacy. She returns the prescription and the correct medication is dispensed. 

D. A 50-year-old patient who had an abnormal mammogram was not advised by her healthcare provider about appropriate follow-up. A mammogram one year later confirms the prior abnormal findings. The healthcare provider now shares the findings, and the patient is referred for further evaluation and breast biopsy. 

The correct answer here is option D. 

First, let's take a look at what kind of a question this is. Given its focus is on malpractice, this is a professional issues question. And, you know, this could occur on any of the NP certification exams. Certain exams have special sections on professional issues, but all of the exams will have a bit of professional issues woven into them. 

Let's take a look at some background information. One description of medical malpractice is as follows: It occurs when a health professional neglects to provide the appropriate treatment, takes appropriate action, or gives substandard treatment that causes harm, injury, or death to a patient. Another view is the failure of a person with specialized education and training, as all healthcare providers have, to act in a reasonable and prudent manner. There are four components to medical malpractice, which the plaintiff must prove. The first is the duty of care. Duty of care is established when there is a patient-provider relationship. Remember, most of the time, this relationship occurs within the parameters of a healthcare practice, primary care practice, hospital system, whatever it is. But the relationship can also be as casual as a neighbor comes to the NP and says, I've run out of my high blood pressure medicine, and I can't get through to my PCP. Could you do me a favor and just refill it for the next month? Keep that in mind when you find yourself as a new grad NP being asked for prescriptions for medications by friends, family, etc. You need to set boundaries. You have to have a patient-provider relationship in place and a record to complete to be safe in prescribing.  

Next would be a breach of standard of care. When looking at the term standard of care, refers to a reasonable degree of care a person should provide to another person, particularly in a professional relationship or health care setting. NPs are duty-bound to use such reasonable, ordinary care, skill, and diligence as nurse practitioners in good standing in the same geographic area and the same general type of practice as other similar providers. When an NP is sued for malpractice, and this of course would apply to any healthcare provider sued for malpractice, the standard of care is argued in court. The attorneys will hire expert witnesses, usually other NPs, who will give testimony describing the actions a reasonably prudent NP has taken in that situation.  

Next is injury or proximal cause. For a malpractice case to proceed, there must be evidence that as a result of negligent care, not meeting standard, there was injury or harm caused. Proximal cause refers to the fact that the injury was caused by that breach of standard of care. Now, with those key components in mind, and yes, when you dig deeply into medical malpractice, there could be several other significant issues that contribute. But that's really like the backbone of what we're talking about.  

With this information in mind, let's take another look at the question. As has been mentioned in other Fitzgerald certification Q&A, you must be able to analyze and synthesize the information to arrive at the best answer.  

Which of the following examples represents a potential malpractice scenario? 

A. A 25-year-old who has been treated for acute otitis media reports penicillin allergy to the healthcare provider. An amoxicillin prescription is given. The patient takes the amoxicillin without adverse reaction. Well, in this situation, the provider was negligent because the patient said, I have a penicillin allergy and the provider went ahead and gave a penicillin form, amoxicillin. So, the provider was negligent, but no harm resulted. Indeed, probably what happened was this is one of the vast majority of people who say they have a penicillin allergy when they don't have a penicillin allergy. And so, the medicine proved to be okay for this person to take. However because there was no harm, the malpractice component of injury was not met. And this is not the correct answer. 

Option B: A 40-year-old patient with acute bacterial rhinosinusitis reports to his healthcare provider that his symptoms have not improved after taking two days of a dose-appropriate prescription for amox with clavulanate. This is also not correct. Failure to approve after three days of appropriate antimicrobial therapy in ABRS is not uncommon, and this person has only been taking the med for two days. Indeed, the ABRS guidelines state that if there's no improvement after 3 to 5 days of appropriate therapy, then another antimicrobial should be prescribed. This would not meet the standard of injury. There was no breach of care because amox with clav is one of the most accepted, indeed, the most commonly prescribed antimicrobials for the treatment of ABRS, absolutely within acceptable practice. If you're thinking, well, what would you do with a patient like this if they contact the office? But you would say is okay, you've been on the antibiotic for a couple of days, give it a few more days. If you're not better after five days, please let us know and certainly let us know if you get worse over the next few days. Usually what will happen is on day three, a lot of times people whose sinus is bothering them a lot, all of a sudden the sinuses start to clear up.  

Option C: Before taking a medication, a 28-year-old realizes the wrong drug was dispensed at the pharmacy. She returns the prescription and the correct medication is dispensed. Well, once again, clearly there was a breach of care standards, but this was at the level of the pharmacy, not the healthcare provider. At least the way it's been worded. Thankfully, the patient noted it and did not take the faulty prescription. Therefore, while I'm sure there was great inconvenience and worry on the patient's part, there was no injury. 

Option D, a 50-year-old patient has an abnormal mammogram who was not advised by her healthcare provider about appropriate follow-up. A mammogram one year later confirms prior findings. The healthcare provider shares findings with the patient, and the patient is referred for further evaluation and breast biopsy.  This is the best answer. One of the most common reasons for a malpractice lawsuit is a delay in cancer diagnosis. While we're not told what the biopsy results were, we were advised that there was a prior abnormal mammogram and the patient was simply not advised. That is a breach of the standard of care because the standard of care says that patients are promptly advised about abnormal findings, whether it's a mammogram, a blood test, or whatever it would be, and that the provider works with the patient on appropriate next steps. 

Key takeaway: Just saying the words medical malpractice can be frightening. To avoid this, the health care provider needs to know its components. Knowledge is the key to the prevention of medical malpractice. 

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