Advanced Practice Provider Case Study: Failure to Monitor Patient Care

By: Janet McCrossen, BSN, RN
2 Minute Read

A patient presented to a medical practice with complaints of shortness of breath, chest pain, and frequent burping. For four months, he was treated by one of the practice’s physician assistants (PA), but over the course of his treatment, he was never seen by the supervising physician.

During the initial visit, an EKG was performed and interpreted as normal, and the PA believed that the patient’s symptoms were digestive and respiratory in nature, providing him with dietary recommendations. The PA also recommended an endoscopy or barium swallow if symptoms did not improve. At a follow-up visit one week later, there was conflicting documentation about chest pain. The PA recommended a full physical exam—but this exam never occurred.

Four months later, the patient returned “in acute distress,” with complaints of shortness of breath, chest pain with normal activities, body aches, abdominal pain, and nausea, and was seen again by the PA. The PA administered Phenergan® IM and ordered a clear liquid diet. The patient was sent home with prescriptions for Phenergan® and Lomotil®.

Only a few hours later, the patient’s wife called to report that her husband’s condition was “getting worse.” She spoke with the PA, who prescribed Vicodin® for body aches and pain. That same evening, the wife called the practice once more, insisting that her husband was no better. During this call, she spoke for the first time with the supervising physician who ordered Darvocet®. The next day, the patient suffered a heart attack and died in his home.

What Went Wrong?

After months of the patient complaining of chest pain, the practice had no documentation to support those symptoms were addressed, and the PA responsible for his treatment never made a referral for cardiac evaluation. In addition, the PA never discussed the patient’s care with the supervising physician, nor did they refer the patient to be seen by the supervising physician at any point throughout treatment.

Key Takeaways:

  • Lead physicians should always assume the appropriate supervisory responsibilities over acts of APPs
  • Acts delegated to APPs should be outlined in a scope of practice document
  • Patients should be periodically monitored by the supervising physician to ensure the APP is consistently providing approved care
  • Practices should develop a written guideline per state-specific regulations for supervising APPs, including when it’s appropriate for a physician to evaluate their patients



For further guidance on issues surrounding APPs, Curi members are encouraged to explore tools and resources included in our state-specific Advanced Practice Provider Toolkits. These toolkits are designed to answer questions related to the scope of practice, onboarding, and supervision of APPs. Members may also reach out to one of our risk solutions experts at Curi Advisory by calling 800.622.7917.

The opinions expressed herein are not intended as legal advice. We have found that the use of such information reduces the risk of medical malpractice claims, but we cannot guarantee that following this advice will prevent a claim against you or your practice.


Janet McCrossen, BSN, RN
Janet McCrossen is a Curi Risk Consultant, based in Philadelphia, PA.

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