Medical malpractice cases involving nurse practitioners (NPs) highlight gaps in clinical decision-making, communication, and adherence to protocols. One case involved an alleged failure to prescribe necessary psychiatric medication, leading to deteriorating patient symptoms and potential harm (JNPA, 2021). This case underscores the need for structured communication, risk management, and adherence to evidence-based guidelines. This case meets the criteria for what I wrote my essay on for the week 1 assignment.

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What Went Wrong?

Several failures contributed to this malpractice incident:

The NP did not follow psychiatric treatment guidelines, missing a critical opportunity to stabilize the patient (American Psychiatric Association [APA], 2021).

There was no documented consultation with a psychiatrist, despite the high-risk nature of the case.

The rationale for withholding medication was unclear and poorly documented, making it difficult to justify the decision legally and clinically.

This case reflects the dangers of miscommunication, lack of interdisciplinary collaboration, and deviation from best practices—all preventable with structured safety strategies.

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Risk Management and Patient Safety Strategies

A multifaceted approach is needed to prevent similar malpractice cases. Closed-Loop Communication (CLC), Implementation Science, and the Consolidated Framework for Implementation Research (CFIR) can help ensure safe, evidence-based decision-making (Damschroder et al., 2009; Leonard et al., 2004).

1. Closed-Loop Communication (CLC)
CLC ensures that orders, decisions, and interventions are verified, confirmed, and documented (Leonard et al., 2004). In this case, the NP could have:

Confirmed the treatment plan with a psychiatrist before withholding medication.

Used a verbal read-back system to ensure alignment among providers.

Properly documented decision-making to protect both the patient and provider.

2. Implementation Science and CFIR Model
To ensure adherence to psychiatric protocols, healthcare organizations should:

Embed clinical decision-support tools in electronic health records (EHRs), prompting NPs to follow evidence-based guidelines (Harrington et al., 2020).

Require mandatory consultations for high-risk psychiatric cases.

Implement regular case reviews to monitor compliance and identify gaps.

Actionable Steps for Prevention
Standardize policies requiring psychiatric consultation for high-risk cases.

Use real-time alerts in EHRs to prompt NPs when prescribing psychiatric medications.

Conduct simulation-based training to reinforce risk management strategies.

By integrating CLC, structured protocols, and ongoing education, healthcare organizations can eliminate preventable errors, improve patient safety, and reduce liability risks.

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References

American Psychiatric Association. (2021). The American Psychiatric Association practice guidelines for the treatment of patients with schizophrenia. APA Publishing.

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(50). https://doi.org/10.1186/1748-5908-4-50

Harrington, N. G., Wilson, R., & Ragan, S. L. (2020). Health communication: Theory, methods, and application. Routledge.

JNPA. (2021). Nurse practitioner medical malpractice case study: Alleged failure to order appropriate medication for behavioral health patient. JNPA The Journal, 11(1), 26–28.

Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(Suppl 1), i85–i90. https://doi.org/10.1136/qshc.2004.010033