Failure to supervise
advanced practice
providers
by Wayne Wenske, Senior Marketing Coordinator, TMLT
his closed-claim study
is based on an actual
malpractice claim from
Texas Medical Liability Trust.
This case illustrates how
action or inaction on the
T
part of the physicians led to allegations
of professional liability, and how risk
management techniques may have either
prevented the outcome or increased the
physician’s defensibility. This study has
been modified to protect the privacy of
the physicians and the patient.
PRESENTATION
A 9-month-old boy was brought by his
mother to his pediatrician’s office for
treatment of a possible insect bite on
the left buttock. The lesion appeared
two days before, and had grown in size.
The patient’s vital signs were 98.9°;
respiration rate 28; and heart rate 130.
The patient’s medical history included
methicillin-resistant Staphylococcus
aureus (MRSA) infection.
Normal vital signs for an infant
(younger than 12 months old) are
temperature at 98.6° when taken
orally and 99.6° when taken rectally;
respiration rate range of 30-60; heart
rate range of 100-160.1
Pediatrician A diagnosed cellulitis and
cutaneous abscess and prescribed
mupirocin and warm soaks to the
affected area.
PHYSICIAN ACTION
Two days later, the mother brought
the patient back to the office reporting
increased illness, pain, fever, and
redness. The patient was seen by a
certified pediatric nurse practitioner
(CPNP). The patient’s vital signs were
temperature at 102.9°; respiration rate
50; and heart rate 176.
The CPNP decided that incision
and drainage (I&D) of the lesion on the
patient’s left buttock was required. To
prepare for the procedure, she ordered
lidocaine, epinephrine, tetracaine (LET)
topical analgesic and warm packs
applied to the patient’s lesion.
A physician assistant (PA) applied
the LET and secured a warm pack
over the lesion with self-adherent
wrap. After preparing the patient, the
PA left the room.
A few minutes later, the patient’s
mother came out of the room, and
asked the CPNP to reapply the warm
pack as it had moved out of place
from the left buttock to the right
buttock. The CPNP returned to the
room and found the patient in distress
in his mother’s arms. The warm pack
had been removed and the patient’s
right buttock was burned.
The CPNP proceeded with the
I&D. The fluid obtained was purulent
and culture was positive for MRSA.
The CPNP documented a seconddegree
burn to the right buttock, and
prescribed clindamycin palmitate
HCI 75 mg/5ml, cool compresses,
analgesics, and to return for follow
up in two days. The mother was also
instructed to bring the patient back
earlier if there was increased redness,
drainage, or other concerns.
The next day, the mother called
the pediatrician’s office and reported
that the burn on the right buttock
was blistered and the size of a sand
dollar or approximately three inches
in diameter. The mother also reported
that the patient’s pain had increased.
The patient was prescribed silver
nitrate topical cream, acetaminophen,
and cloth diapers to maintain moisture
in the affected area.
At the follow up appointment,
the pediatrician saw the patient,
documented blistering, and referred
the patient to a burn center at a large
local hospital. At the burn center, a
full thickness burn (third- and fourthdegree
burn) was noted. Over the next
nine weeks, the patient received burn
treatment and fully healed. The patient
has residual hyperpigmentation in the
burn area.
ALLEGATIONS
The patient’s family filed a lawsuit
against the pediatrician’s office
alleging:
• failure to adequately supervise
the CPNP and PA; and
• failure to adequately treat the
patient.
The lawsuit included claims for the
patient’s pain and suffering, residual
scarring, need for future scar revision,
and parent’s lost wages for several
weeks at home caring for the patient.
LEGAL IMPLICATIONS
Consultants for TMLT were critical of
the care provided in this case. All of
the consultants questioned the use
of warm packs that were so hot they
would produce third- and fourthdegree
burns to an infant. They also
criticized the poor supervision of the
application of the warm packs.
Another consultant believed the
CPNP’s decision to perform the I&D
procedure was not indicated.
DISPOSITION
This case was settled on behalf of the
pediatrician’s office.
20 Dallas Medical Journal May 2019