Competence Or Compromise

Voiceover: Every minute someone’s life takes a terrifying detour not down a dark alley, but into the sterile, bright halls of healing. They walk in seeking care and find themselves plunged into a nightmare. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care, which accounts for more than half of the paid malpractice claims, are related to missed or late diagnosis. 

Now, before you raise a pitchfork at every white coat you see, let’s be clear this isn’t an indictment. It’s a revelation. Because the truth is, any provider, any nurse, any human being capable of brilliance is also capable of a mistake. This is about understanding why and using that knowledge to build a safer future for every patient who walks through those doors. 

Welcome to FHEA’s Scrubs and Subpoenas: Tales from the Witness Stand, a podcast where we’ll peel back the sterile sheets and delve into the real stories of medical malpractice. Each episode a cautionary tale, a blueprint for change, a reminder that even in the darkest corners of human error, there’s a light, the light of knowledge, the light of empathy, the light of a future where healthcare becomes not a gamble, but a guarantee. 

So, join us as we dissect the mistakes, illuminate the flaws, and ultimately learn to heal not just bodies, but the very system itself. 

Jannah Amiel: Welcome to another episode of Scrubs and Subpoenas: Tales from the Witness Stand. I will be your host and joining me-I should say my name, huh? Jannah Amiel. I feel like at this point, everybody, you’ve heard my voice if you’re watching this enough. But joining me, of course, is Dr. Sally Miller. Dr. Miller, how are you? 

Sally Miller: Good morning, I’m well, thank you. And you? 

JA: I’m good. I’m good. Thank you. Thank you. Now, Dr. Sally Miller, of course, is one of our amazing faculty here at FHEA, and she serves as an expert witness for medical malpractice cases. So, during these episodes, we get to hear and kind of, like, walk through these actual scenarios and these cases with Dr. Miller and get the opportunity to kind of guess and think about what side she served on. 

And identify different red flags, different strange, kind of, outliers that might stand out in the story. And really the goal of these, always, is to be a learning opportunity, right? Mistakes happen, mistakes happen quite literally every day, everywhere, in every scenario you can think of. And healthcare is not an exception, right? We are not an exception because we’re healthcare providers. We make mistakes because we’re human. And so, this is an opportunity to take some of this stuff back. 

Take what we learned, use these takeaways to practice to the best of our ability for ourselves, right? For our facility, for our patients. Now, I have paper ready and I have a pen ready because I heard that the story is one that’s got maybe a lot of nooks and crannies I got to think about.  

So, if you’re listening, I always advise that you do the same thing. Really listen, follow along, see what you’re picking up on. 

And let’s break this down together and see what we can take away. So, Dr. Miller, I’m ready when you’re ready. 

SM: I’m ready. And like I mentioned to you before we actually started recording, I think this case is particularly relevant because we do have, you know, one of the trends now for nurse practitioners is dual certification or multiple certifications. In fact, I think we have a career night coming up around that sometime later this year, right?  

JA: Yeah.  

SM: So-and when you’re considering, you know, the ‘should I, shouldn’t I,’ pros, cons, cost benefit stuff like that, this might be one of those circumstances that comes to mind. So, the story is about a nurse practitioner, of course, I guess you would probably figure that one out. About a nurse practitioner, she is a family nurse practitioner. She’s a family nurse practitioner that works on a gynecology-oncology surgical service. So, she works for this practice that does-GYN oncology surgery. Her training and certification is as a family nurse practitioner. 

And she is also an APRN first assist. So, you know, there are RN first assists who go through a rather exhaustive training program to serve as a first assistant in the operating room. And then there’s actually APRNs who can go through the first assist program as well, but there are some additional information there about post-op management, things like that.  

JA: Really? I’ve never heard of a first assist. 

SM: You’ve never heard of a first assist? Yeah, first assistants. I mean, a first assistant in the OR-is actually clearly an important position, but there are people who, there are surgeons who make their living that way. Like that’s all they do is contract out as a first assist for the attending surgeon. And RNs can also be first assistants, but they go through a pretty intense program. I mean, it’s not like a couple of hours of CE. It’s pretty exhaustive. It involves a clinical component and then they can serve as the first assistant and bill more for it. 

JA: Yeah. 

S: And then APRNs, and you see this mostly with acute care APRNs, can go back and do the first assist program, but there is an APRN component or an APRN addition where not only are they doing the technical skills in the OR, but then it expands to the post-operative management. So yeah-so this nurse, as an RN, apparently as an RN, she had surgical experience and then she went to a family nurse practitioner program. 

JA: Interesting. 

SM: And became certified as an FNP, but has only ever worked for surgical services as an NP. And she was additionally a trained certified first assistant. So, she’s working now for this service. So, the background of the story about the patient is there is this 67-year-old female patient. And every time I say 60-something that resonates with me. I’m like, ‘Gosh, that could be me.’ Anyway, she’s a 67-year-old female. 

JA: Okay. 

SM: With a remote history of ovarian cancer and a remote history of renal cell carcinoma. These were all like years ago. And I think the kidney cancer for which she had a partial nephrectomy was more than 10 years ago. And then the ovarian cancer I believe was 3 years ago. And so, at this point, now at the age of 67, she has had a partial nephrectomy. She has had an oophorectomy of the one ovary. 

But she still has some stuff in there, you know? And apparently now she has a mass. So, she was recently diagnosed with a 3-centimeter mass in her pelvis and it was causing some obstruction to the ureter, which is how she wound up in care. She was having some urinary symptoms and then she had an abdominal CT and identified this 3-centimeter mass. And so the mass was sort of like entwined and apparently it was in a place where it really wasn’t-biopsy wasn’t the best option. 

JA: Yeah. 

SM: You know, it could have been biopsied, but it wouldn’t have been that easy. It would have, you know, just required like a whole exploratory lap and all that stuff anyways. And so, ultimately, they opted-the advice to the patient was to just have the entire mass excised, you know, better than trying to like, I don’t know, get in there. And I don’t remember all the particulars, but I do know that taking the mass out was asserted as the prudent approach by the surgeon. 

JA: Okay. 

SM: And the patient was counseled that way. And she was nervous about it. Like there was a note in that pre-operative consultation that the patient was nervous. She had had, you know, surgical procedures before, but ultimately she decided to do this. So, this procedure was not supposed to be an especially difficult one. She was admitted on a Friday morning and the plan was to do the procedure that day, an overnight stay, and then she would be discharged to home the next morning. And that’s what happened. She had her surgery on a Friday. 

JA: Okay. 

SM: And she stayed over the hospital Friday night and Saturday morning she was doing well and she was discharged to home. So, that night after the surgery, the surgeon always comes in and has a look at you, but then the surgeon was going out of town for the next several days for-I think coming to Las Vegas for a conference if I remember correctly. So, the surgeon was going to be away for several days after the procedure, but the nurse practitioner on the service, she was covering call. 

JA: Wow. 

SM: So, that night she rounded on the patient and the patient was stable. And then on Saturday morning, the nurse practitioner went in to make rounds. She made rounds in the hospital. She saw the patient and she discharged the patient to home. She documented a physical exam was normal. She noted that there was some mild abdominal discomfort, which is of course to be expected. She documented that the incisions were okay, that they looked good. Bowel sounds were present. The patient was tolerating PO. 

JA: Right. 

SM: She was asking to ambulate and the complete blood count and metabolic panel that were done that morning were all within normal limits. So, it was a good-you know, nurse practitioners usually do document better detail than our other counterparts in the healthcare population. So, it was a good note. It really included all of the things that it should include for this lady who was pos-op. And so, she was discharged at home. So, that was Saturday morning. So. 

JA: Okay.  

SM: I guess she was home on Saturday, she was home on Sunday. On Monday, her husband brought her into the emergency room. Her husband brings her in. At this point, she is confused. She has an altered mental status. The husband reports that she had been having worsening pain over the weekend, but that she became more and more confused, and more and more pain. 

JA: No.  

SM: In the notes he said that she wasn’t eating. And so, finally he brought her in 2 days later. No idea how long this was going on, but the poor guy-you know, I mean, just-I mean, I feel so sorry for families who later on they’re like, ‘Should I have come sooner?’ You know, they don’t know. And the patient, as long as the patient’s not confused, you know that she’s saying, ‘I don’t want to go back.’ But anyway, here she’s back 2 days later. She’s confused. She’s had a progressive change in mental status. She was documented on admission to the ER as unresponsive. 

But then it sounds like through the ER visit, like she came and went, you know, it sounds like she was just kind of stuporous and obtunded.  

JA: Yeah.  

SM: She was found to be hypoxic in the emergency room. She was found to have an ileus by radiography and she was in acute renal failure with a creatinine of 5.6. So, remember 2 days ago, she had a normal metabolic panel. So, she’s definitely gone into acute renal failure very quickly. 

She still had a good blood pressure in the emergency room. It was like still like a hundred over something. But overall, she was septic. Overall, she met septic criteria. Her respiratory rate was 36. Her pulse was 112. You know, mental status change. Her white cells were elevated. I mean, not as much as you would have expected actually, but overall she was diagnosed as septic with an intra-abdominal source. So, the same NP is on-call. The surgeon is still out of town. 

JA: Yeah. 

SM: At a conference in Las Vegas. So, the NP is on-call on Monday. So, the emergency room called the NP. The NP comes in to see the patient, again, writes a very detailed note, calls the surgeon who is out of the state, and they have a conversation. And ultimately the surgeon decides that this is not a surgical abdomen at this point, that it’s sepsis with an abdominal source, but that she doesn’t need surgery.  

So, the GYN-oncology surgeon tells the NP, ‘We don’t need a general surgery consult.’ And the NP agrees, and this is an experienced NP who agrees. So, they both agree, no need for a general surgeon. So, the NP documents a note, she documents the findings of her examination. She documents that she discussed the case with the surgeon, that they agree that there is no general surgeon needed at this time. Now, as you can imagine, every consultant under the sun is being called in here. 

JA: Yeah. 

SM: You know, she’s-so it’s infectious diseases, it’s critical care. Like this is what you’ve got a mental status change. This is what happens. They have everybody consulting, but they decide that no surgeon is needed. For the next 2 days, the surgeon remains out of town and the NP is making the rounds. And again, the NP’s notes are really among the best of the lot, but neurology is making rounds, infectious diseases is making rounds, GI-like everybody and their brother is making rounds and documenting their notes. And she’s being treated for sepsis.  

Nobody mentions anything about a surgical consult or needing surgery until the GYN surgeon comes back. So, he comes back from his conference and he goes in to see the patient on the third day and he deduces that they need to do an exploratory laparotomy. 

So, the patient goes to the OR. Now, of course, she is profoundly septic and the abdomen is cleaned out. You know, the abdomen is cleaned out, but she, you know, she’s like sewn back up and goes back to critical care, but she really doesn’t recover. You know, it’s just-and again, anybody who’s been like an ICU nurse or an ER nurse, you’re like, you know what I’m talking about. It’s just every day rounds, every day, try to wean her. You know, is she more alert today? What are the labs like today? 

JA: Mm-hmm. 

SM: So, she’s still alive, but she’s not really improving very much. Finally, 13 days later, she was made a DNR by her husband and she’s transferred to long-term care. And, you know, eventually, I mean, she goes to long-term care, but eventually she does not survive. She was only 67. I know, I know. You’re not Whistlin’ Dixie there. So, then- 

JA: So young. 

SM: So, a couple of things for everybody who’s listening. I’m not saying there’s malpractice here. I’m saying you need to consider malpractice, which is a very distinct definition. Malpractice means that the healthcare provider failed to do what a similarly trained and experienced healthcare provider would do in the same or similar circumstances, and that that failure was the direct result of the poor outcome of the damages.  

So, we have-that’s the consideration. That’s all that really matters about malpractice. But the emotional piece is what comes in. And even-I’ll bet as some people were listening, cause I know, I mean, all of us-you hear the story and go, ‘Man, that could be me. That sounds so awful. My gosh. Why didn’t they do this? Why didn’t they do that?’ And that’s what juries feel too, you know? 

JA: Yeah. 

SM: So it’s-I mean, practically speaking, if something actually gets to a trial, it’s not just about the facts and the legal interpretation of malpractice. There is also the emotional piece. And as an expert, I mean, our job on either side of the expert file here is to advocate for the factual piece, the evidence-based care piece, and try to leave the emotion out of it. But in real life, the emotion doesn’t get left out of it. 

And so, and the reason I mentioned that here is because remember I said, like in this lady in the initinial surgical-did I say initinial? I made up a word. In the initial surgical consultation, she was scared. It’s like he had in the note that she was very concerned and she had had cancer twice before and she was concerned about missing cancer, but she was concerned about operation. And it really tugs at your heartstrings to know that coming into this, she was scared. 

JA: You sure did. Yes, yes it does.  

SM: I mean, I’m like, gosh, I can totally identify with that. This is like the ultimate countertransference. I could feel how she is, but that’s really not supposed to matter. The question here is did-and so of course the nurse practitioner is the subject of the lawsuit. So, the assertions of the nurse practitioner primarily centered around that she wasn’t competent to make the determination that a surgical consult wasn’t needed. 

Like where they came at the nurse practitioner was number one, that she was not competent to make rounds on Saturday morning and decide that this patient could go home. You know, that that wasn’t her skill set. And then that when the patient came back a couple of days later and she went to the emergency room, that she was outside of her scope and not competent to make the determination that a surgical consult was unnecessary. And then as she continued to make rounds that she should have initiated the surgical consult.  

That’s basically like I’m paraphrasing here, but that was the first thing that they went after her for. So, you know, ask the-you know, ask the listening audience here. So, this is how you can decide based on the info that I shared with you about the documentation. Do you think she was competent? You know, do you think she was competent? Will the jury think she was competent, that kind of thing. But where the plaintiff’s attorney really took this was that she was a family nurse practitioner.  

And why is a family nurse practitioner managing a surgical patient? And is a family nurse practitioner appropriately trained and educated to make these decisions? And so, they pull out like the whole, the AANP’s scope of practice and standards, they pull out the laws. And with the family nurse practitioner the language is all about primary care setting and blah, blah, blah.  

And so, they really-when push came to shove, were trying to use the fact that she was a family nurse practitioner practicing in this acute care setting on this GYN-oncology service and therefore was not qualified to make any of these decisions. 

JA: I mean, I don’t want to be that guy, but is she? 

SM: Well, so ultimately that’s for the jury to decide. But-and actually in the particular state in which this occurred, the State Board of Nursing has an advisory opinion for nurse practitioners practicing in the acute care setting. Like not just to FNPs, but anybody they had an advisory paper for NPs practicing in acute care.  

And actually, like a lot of states don’t, but this state did. And it was actually really supportive of this NP. It was actually really helpful in the case. So, what it says is keeping in mind that the population of acute care NPs is really very small as compared to family nurse practitioners in the country. So, there was a paper written, I can’t think of who wrote it, but I found it. And I knew that there was this data out there and I found it for this case. There was a big study about the certification of nurse practitioners working in the acute care setting.  

And at that time, when I got this case-it was something like 6 or 7 years ago. At that time, over 50% of all of the nurse practitioners practicing in acute care were family nurse practitioners. 

JA: Wow. Like alone, not with dual certification?  

SM: Alone. And so, when you remember that by definition, you know, the same or similar circumstances with someone with the same education, the same or similar circumstances. So, is it consistent with the standard of care for a family nurse practitioner to be practicing in the acute care setting? And if you consider that more than half of all the NPs in acute care are certified as a family nurse practitioner, then the answer is yes.  

Now I can feel the acute care NPs listening going, ‘No, no, we have a special skill set.’ So, to anybody who’s listening-by the way, I’m both, I see this from both sides of the aisle. In fact, I took the very first acute care boards that were ever offered in December of 1995.  

JA: No. 

SM: And I took-I mean, before then we didn’t have a board certification. We just weren’t working there. We learned how to work and then we worked there. But yes, I am certified in acute care and I totally appreciate the differences in the certification, I understand it.  

But again, that’s not necessarily the law. If the law allows for this NP to practice in that setting, and she is appropriately trained and experienced to do so, well then, she can. So, for this particular NP, what really supported her was that number one, the State Board of Nursing had an advisory opinion stating exactly that that there is a role for the family nurse practitioner in the acute care setting, provided that the family nurse practitioner is appropriately trained, et cetera.  

But also remember that this NP was an APRN in first assist. So, she was trained in the management of surgical patients, not just first assist, but actually if you look at the curriculum for APRN first assist, they are trained in post-operative management. 

JA: Yeah, yeah. 

SM: So, in this particular circumstance, not only did she have the training, she was certified as an APRN first assist, she was experienced, and her only other job as an NP before this one was for a surgical service. So, she was clearly experienced. She was, and actually she was probably more appropriately practicing in a surgical service than family practice, you know? 

JA: She’s like full of surgical experience. 

SM: And also keep in mind that as long as the law allows you to practice there in your state, appropriate training doesn’t necessarily mean academia. Appropriate training absolutely can mean on-the-job training. And so, the thing that I would suggest for anyone who is working in one practice setting, but their certification is in another, if you feel appropriately trained to do so, document it in some way. Even if it’s just that you set up like a protocol, like a checklist thing.  

So, if you’re an FNP and you’re going to work in critical care pulmonary, so part of your job might be putting in central lines, part of your job might be intubating, part of your job might be making decisions about transferring people to various levels of care. You know what? Get that procedure manual, get a job description and a procedure manual, and then a checklist and have whoever trained you how to do those things just sign off that you know that you can do them. 

That you are trained and experienced to do-like something like that. So yeah, like now some states laws are very specific that you can’t practice outside of your certification. Mine is like that in Nevada. Now Nevada, interestingly, does not acknowledge acute care nurse practitioners as a separate specialty. Our law, you really got to dig into the law. See, this is the advantage of having been the APRN consultant to the board for a couple of years. 

JA: Yeah. No kidding.  

SM: Nevada specifically identifies family nurse practitioners, psych-mental health nurse practitioners, women’s health nurse practitioners, pediatric nurse practitioners. So, if you’re certified in those things, you cannot practice outside of it. If you are a family nurse practitioner, you are not supposed to be working for a psychiatric practice. If you’re a pediatric nurse practitioner, you should not be seeing adults even if they’re 22, like that kind of thing.  

But my state, the law, doesn’t recognize acute care nurse practitioners as a separate certification. So, if you want to practice in acute care, you just need to substantiate, not for the state really, but for your own self. Like if you want to practice in acute care, well, if you’re a family nurse practitioner, then you can see anybody in acute care. If you’re adult-gero nurse practitioner, you can see adults in acute care. And if you’re a pediatric nurse practitioner, you can see peds in acute care, but you do want to be able to substantiate that you are appropriately trained to do so. 

JA: Wow, that’s really interesting. So, like all those laws are super important to understand that. 

SM: They are, and then even if like-first of course you have to be following the law. So, like if, you know, if you are a pediatric nurse practitioner and you want to work for a surgical service that sees adults, you can’t do it until you have an NP certification that includes adults. So, there’s that, like you got to have the law first. But even if the law is silent on the topic- 

JA: Right. Yeah. 

SM: Like, if you’re an FNP and you want to practice in the acute care setting, well, legally you can, but you really want to be able to demonstrate that you are appropriately trained, experienced, and educated to do so if you ever get sued. 

JA: Yeah, just in case. 

SM: And more and more and more facilities are now requiring nurse practitioners that practice in acute care to be acute care certified for exactly that reason. Because of course, if there is a lawsuit like this one, you know that the facility is also being sued for, like, allowing this person to have privileges there when they’re not an acute care NP. So, the facility needs to be able to substantiate that they have appropriately hired, you know, et cetera, all that kind of stuff. 

JA: Mm -hmm. Yeah. 

SM: So, it can be a big-it’s just a big mess when we’re talking about dual certification. So, for the person who’s trying to decide if it’s really worth going back to school and spending that money and taking another certification exam, listen, if you have years and years left of your career and you really want to work in that setting, yeah, it’s worth it. It is.  

Because that clearly substantiates that you are academically prepared to work there, like it’s indisputable. If you have strong experience and you don’t want to go back to school and spend all that money, but you are very sure that you can substantiate your experience. Well, as long as the state law allows it, well then sure. So, there’s so much that goes in the decision-making process, but so many, just when you’re coming out of schools and NP, like I said, most new NP grads, they’re very focused on individual patient care. Do I know how to diagnose this, assess this, order this?  

Like particular patients and all of these other things and really don’t necessarily have a good understanding of the implications of the law versus the implications of a malpractice action because they’re not always the same thing. You can be legally authorized to do something but if you do it and something goes wrong, one of the first things they always go after is well are you actually qualified to do it? Should you be doing it? You know? 

JA: Right, right. Like what supports that you actually can. Wow. Okay. Before I ask what happened, one of the things I’m thinking, I have a question and this might be silly. Maybe this is like a weird RN hierarchy thing that I can’t get out of my own brain. But one of the things that you said was, you know, like she didn’t have-I don’t want to say their rights, but like wasn’t-couldn’t appropriately determine if like this patient needed a surgical consult or not. 

But like going through that story, right, sounds like she consulted other providers as well to like reaffirm or not that this client needs to have a surgical consult. Like we need surgery or we don’t need surgery. Meaning-I guess my question is, can she alone make that decision or is she alone responsible for that if everybody on that healthcare team was also like, ‘No, no , no, we don’t need surgery. No surgery, no surgery, no surgery, no surgery.’  

Can the APRN say, ‘I don’t trust any of that, we need to do surgery?’ You know, like, how does that work? 

SM: Depends who you ask. Depends if he asked the plaintiff’s attorney or the defense attorney. So, I mean-so you have a primary service and then you have consultants, right? And this patient was a patient of-the primary service was GYN-oncology surgery. So, it was their patient. So, that’s the service that initiates consultation. And consultation is really only there to evaluate their piece in the world. Now, and a patient like this, critical care is also consulted and it depends on the hospital hierarchy and they’re not always the same, but very often for a critical patient, critical care takes over that kind of decision-making in the acute phase.  

So, it would be very appropriate and reasonable for critical care to have opined on whether or not a general surgery consult was needed or not. And- 

JA: Yeah.  

SM: Even though all the other consultants that come in-I mean, they were all there, you know, neuro, cardiac, GI, infectious diseases, even though they’re there for their peace in the world, they will usually advise if they think another consultant is needed, they will usually advise it like when they do their consult note and then at the end, these are their recommendations, recommend this for this, you know, this antibiotic and recommend that and recommend consult surgery. And they usually will if they think it’s appropriate. Do they have to? No. 

JA: Yeah. 

SM: It’s ultimately the role of the primary service to determine what consultants are needed. So, it is in the purest sense-it was for GYN-oncology to decide which consultants should be called in, but they did consider it and she talked with her attending about it. Now the plaintiff’s attorney basically was saying that she didn’t give the consulting surgeon enough information-not the consulting surgeon. She didn’t give her collaborating GYN surgeon who was out of town. They were saying she didn’t give him enough information, that he was making his recommendations based on the info she provided and that she was not competent to make that assessment.  

That’s what they really tried to get at. And of course, from her perspective, well, number one, she was competent. I mean, our position was she was competent to make that determination based on what we’ve already talked about. 

JA: Yeah. 

SM: She was competent to make it. Aside from that, she did appropriately present the patient to the GYN surgeon, and ultimately it is his call. And that even though the consultants are not required to make recommendations, it certainly is supportive that none of them did recommend general surgery. So, they all strengthen her position here, but in the end, no, it’s up to the primary service to decide what consults are necessary. 

JA: Yeah. Yeah. That makes sense. That makes sense. So, I’m going to guess you were on the defense side. 

SM: I was on the defense side of this one. It is a sad story. I mean, it’s a sad story, but all it really comes down to was, was she competent to make these assessments? Did she do it properly? Did she miss something? And I genuinely don’t think she did. Now again, there was a settlement here. There was a settlement, so it’s a sad story.  

JA: Yeah, it is. 

SM: It’s very easy to Monday morning quarterback and say, ‘Yeah, they should have consulted general surgery.’ I mean, of course you can always-if you know how something’s going to end, you can always go back and say, ‘Shoulda, shoulda, shoulda.’ But, no-but I mean, I don’t know. I don’t, I’m not a GYN-onc surgical person. So, you know, I don’t know. I mean, when I was first looking at this, I thought, ‘Geez, I don’t know. I might’ve called surgery, but-’ 

JA: Of course. Wow. 

SM: But he was the surgeon and he was the surgeon that did the procedure. And so, I would defer the judgment call to the person that did the procedure about what else needs to be there. And did it turn out to be the right call? I mean, I don’t know if it would have made any difference or not, frankly. Who knows? Who knows? 

JA: Yeah. Who knows, right? We’ll never know, we can’t know, right? And that’s a game that we play. And unfortunately, I think that that’s the game, to your point earlier, the family plays and that kind of is the worst of it all. Like, is there something else that I could have done? Should I have done something sooner? Should I have called the first day? Yeah, those are rough. Those are rough. Wow. 

SM: Mm-hmm. Yep. Yeah. 

But for any of our NP audience, if you’re considering second-I mean, first of all, it really is a testament to not practicing out of scope. It’s just not a good idea. And if you are experientially prepared for something, you do want to make sure that you can document it. It’s just, it’s the one time. It’s the one time, even if you didn’t do anything wrong, if it comes under the microscope. So, in this case, I mean, I was just very grateful that she had all of this clear- 

JA: Yeah. 

SM: Not just academic experience, but also experience. She also had that 25-page HR file. She was credentialed by the facility. There was a whole skills checklist and all that kind of stuff there. So, it was very easy to support. I wasn’t there to support whether or not her decision was right or wrong. It was, was she qualified to make her decision. 

JA: Yeah. Yeah. Wow. This was a very interesting story and definitely a good one for scope for certification, especially as you mentioned, those that think about it are kind of like, I don’t really maybe need that. I mean, this just might be a little extra layer of protection. Should you ever need it and really benefit to you, right? It benefits to you because it will equip you with the things I think that you’ll need to know. 

SM: Mm-hmm. 

JA: Thank you, Dr. Miller, so much always for your time. We really hope that you enjoyed listening to this story and got some good takeaways from it. And if you want to hear more and see what else we got going on, check out our other podcasts and our courses at FHEA.com. Thanks for listening, everyone. Goodbye for now. 

Voiceover: Thank you for listening and learning with Scrubs and Subpoenas: Tales from the Witness Stand presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com. Join us again next time as we dissect more medical malpractice cases.