Risk management lessons from a ‘nuclear’ PA lawsuit verdict

During a flu outbreak, a 48-year-old male patient visited an urgent care facility with malaise, a fever, fatigue and dizziness. Although the rapid influenza test was negative, the PA figured it was a potential false negative, diagnosed the patient with influenza and prescribed Tamiflu.

The visit and examination lasted approximately 20 minutes.

What happened next led to a lawsuit against the PA and a “nuclear verdict” from a jury — an award exceeding $20 million. 

The patient was unable to walk back to his car and a clinic technician had to assist the patient using both a gait belt and wheelchair. His condition deteriorated over the next few days with severe confusion. When he finally returned to the emergency room, he was diagnosed with a stroke. 

The patient sued, and the initial defense settlement offer of $250,000 was declined. The case subsequently went to trial. The jury returned a verdict against the PA with a catastrophic judgment exceeding $20 million. The urgent care facility was notably absent from the verdict form, likely because of a pre-trial settlement.

While no clinician can avoid all legal risks, Randy Danielsen, PhD, PA-C Emeritus, renowned PA educator and author, shares key lessons from this case that can help PAs protect themselves from litigation while improving patient outcomes. 

1. Maintain a broad differential diagnosis

One of the most common reasons for misdiagnosis is cognitive bias — when a clinician anchors on the most apparent diagnosis without considering alternative possibilities. In the case of the misdiagnosed stroke, the PA allowed the more common conclusion to override the clinical presentation. “You see so many influenza patients, and with most of them, you’re correct. The point here is that we can’t be led by the nose down that road,” says Dr. Danielsen.

To minimize this risk of biases:

• Think beyond the most common diagnosis. If a patient presents with flu-like symptoms but has malaise and is dizzy or confused, consider a stroke or other severe conditions.
• Document the thought process that leads to a diagnosis. If you rule out a condition, explain why. Thorough notes can be crucial in showing you met the standard of care.

2. Recognize red flags

Urgent care settings, by nature, make it difficult to know patients’ medical histories thoroughly. This is why asking all the necessary questions during the appointment to identify any atypical presentations is especially important. “Even if you have a waiting room full of people, take the time to conduct an appropriate history and physical exam,” says Dr. Danielsen. 

In the case of a misdiagnosed stroke, a typical influenza  patient doesn’t usually need assistance to leave urgent care. This was a critical warning sign that the defendant and the urgent care center missed. “Somebody from the clinic had to help the patient out to the car — that ought to send up a red flare,” says Dr. Danielsen.

Patients don’t always present textbook symptoms. Be especially cautious with:

• Neurological signs and symptoms
• Out-of-proportion pain
• Elderly and immunocompromised patients
• Pediatric patients

3. Order tests and imaging when necessary

While avoiding unnecessary tests is good practice, failing to order appropriate imaging or labs can lead to catastrophic outcomes.

• Use shared decision-making. Discuss a test with the patient and document the conversation if you think it is borderline.
• Know your facility’s limitations. If you work in urgent care without access to advanced imaging, send patients to the emergency room when necessary.
• Understand the limitations of rapid tests.

4. Communicate clearly and document thoroughly

Poor documentation is a significant vulnerability in malpractice cases. If it’s not in the notes, it didn’t happen in the case of a lawsuit. To protect yourself:

• Write down how you came to a diagnosis. Even if you ultimately treat one condition, listing and ruling out others shows you considered multiple possibilities.
• Document patient refusals. Document the discussion, including the risks explained if a patient declines a test, referral or treatment. This is also true if a patient insists on just going home.
• Provide clear discharge instructions. Make sure patients understand when to return or call if symptoms worsen.

5. Stay humble and ask for advice

If you feel uneasy about a patient’s condition, take the time to ask a colleague. “I’ve been a PA for a long time, but I like to be humble and remember I don’t know everything, and so if I have any issue, I’ll ask my collaborating physician or a PA colleague to take a look,” says Dr. Danielsen

• A second opinion can provide legal protection even if you feel confident in your diagnosis.
• If a patient’s condition exceeds your facility’s capabilities, arrange for transfer to a higher level of care.
• If you think a patient needs hospital admission but another provider disagrees, document your concerns and escalation efforts.

6. Have malpractice insurance

Even the best clinicians can be sued. This case, when the PA was the only one to go to trial, underscores the importance of having a personal professional liability policy in addition to your employer’s policy.

Make sure you have:

• Tail coverage. If you change jobs, ensure you are covered for claims arising from previous work.
• License coverage. An allegation can damage your reputation and even cause your license to be revoked. License coverage helps you defend your license in the case of a state board licensing complaint.

Risk management checklist for PAs 

Finally, Dr. Danielsen offers a mental checklist he recommends all PAs carry with them into the exam room to avoid dangerous and costly mistakes.

1. During outbreaks, especially, don’t let that skew your diagnosis. 
2. Never jump to a conclusion without a thorough exam.
3. Ignore the pressure of a full waiting room, and take the time to do what you were trained in PA school to do.
4. Listen to the patient. They will tell you what’s wrong with them.
5. Don’t ever give up your integrity.

Misdiagnosis lawsuits can be devastating, but proactive strategies can significantly reduce the risk. Staying vigilant and prioritizing patient safety isn’t just good medicine — it’s the best legal defense.