Some of the most important risk areas related to advanced practice providers (APPs) or mid-level providers include: credentialing, scope of practice, communication, and supervision.

First, with respect to credentialing, providers have different backgrounds, experience and training, so it is critical to have a formal credentialing process that includes orientation, proctored shifts and review of documentation. Also, the scope of practice for APPs is quite variable in emergency medicine today. APPs are being used in fast tracks, wound care centers, urgent care centers, and the main emergency department.

Adequate communication is essential to successful risk management. Communication and hand-offs must be addressed, as they are frequently identified as the cause of errors in patient care. Also, APPs should be kept in the loop of departmental meetings, peer review, hospital updates, and changes in policies and procedures or practice guidelines.

When left out of the loop, APPs may feel that they practice in isolation from their physician colleagues. Also, as health care changes, roles for certain APPs may expand, causing changes, and therefore increased risk, in the supervision of APPs. States may have clear regulations regarding scope of practice, appropriate supervision, and staffing ratios.

In some states, certain APPs may work independently, while in other states they are expected to work closely with their physician colleagues. State regulation may mandate differing degrees of supervision for varying types of APPs. As regulatory efforts regarding supervision increase, effective compliance programs should reflect the changes in the supervision requirements to reduce risk, as inadequate supervision can result in diagnostic error and delayed treatment or other allegations of negligence.

Case Study: The patient presented to the ED with a headache and was diagnosed with a sinus infection by the APP. The patient was placed on antibiotics. The patient returned a few days later with a subarachnoid hemorrhage. In this case, the APP had not passed his boards and was not licensed. It was later reported that the physician was using this APP as a scribe but allowed him to see the patient. This shows failures on many levels: verification of the provider’s credentials, assurance that work was within scope of practice, and proper supervisory oversight.

Case Study II: A patient presented to the ED complaining of back pain and left arm discomfort. The patient was examined by the APP and, based on the fact that the pain was relieved by medication that he felt would not relieve cardiac pain, received a diagnosis of musculoskeletal pain and muscle spasms. The APP did not realize the patient had experienced an acute coronary event.The patient was discharged with prescriptions for pain medication and muscle relaxants. The APP did not consult with the supervising physician in a timely manner, and the physician did not review the medical chart until the following day. Unfortunately, the patient by then died of a heart attack. This illustrates that the supervising physician should be available at all times for consultation and should encourage consultation in high-risk complaints, even if not mandated by regulations, policies, and procedures.