Vol. 5 Issue 23
Question & Answer
Challenging Status QUO
What to do when an existing procedure becomes questionable
Q: An RN works in a clinic that was bought out by a hospital a few years ago. She's been there nearly a year and has an ongoing problem. The unlicensed clerical staff members continue to take verbal orders and call prescriptions to pharmacies as they did when the clinic was a private practice. In the RN's mind, this procedure should have stopped once the hospital bought the practice. She doesn't feel comfortable in this situation and has voiced her concerns to her manager numerous times. The manager understands the RN's dilemma, but no action has been taken to correct the situation. She is the only RN in the office. Where does she stand?
A: As nurses, it is our responsibility and duty to provide excellent care to all our patients, whether they are in an inpatient hospitalization or an outpatient clinic setting. A situation where unlicensed clerical staff not nurses or physicians are calling pharmacies with prescriptions causes high alarm for potential medication errors. Nurses also are held accountable for all doctors' orders taken and carried out. Unlicensed clerical staff should not be permitted to take any verbal orders from doctors. The nurse's training has allowed her to receive a license that gives the RN the authority and experience to understand doctors' orders.
The issue of liability and accountability falls upon the nurse, manager, doctors and hospital clinic if this practice continues. The RN should have the support of her manager to discuss this dilemma with those involved. If the RN continues to experience this problem, her only choice is to resign and, therefore, not be involved with this kind of practice.
This practice definitely does not promote patient satisfaction due to possible delays in receiving medications at the pharmacy and clinic treatments. The overall goal is to provide excellent care to patients, and having trained staff handle certain responsibilities will ensure less medication errors and less incident of treatment errors.
Arlene R. Caselli, RN
A: It is not uncommon for office staff to have presigned medication prescriptions that enable them to fill in the blanks based on the patient's chart, or for physicians to give verbal orders to be telephoned into the pharmacy. But who can receive and transmit medication orders in clinics is actually a legal issue.
The nurse needs to check with her hospital's legal department and/or state pharmacy board to learn whether it is legal for clerical staff to take verbal orders and telephone them to the pharmacy or fill in prescription blanks for patients. Although her clinic may be in full compliance with state laws and regulations, it may not meet with JCAHO since hospital-owned clinics are usually subject to the same accrediting standards and surveys.
Legal and regulatory issues aside, patient safety should be paramount. Medication errors reported to the U.S. Pharmacopeia-Institute for Safe Medication Practices' Medication Error Reporting Program reveal that presigned prescriptions and verbal orders are weak links in the medication safety chain.
For instance, a prescription printed by the clerical staff for once-a-week Fosamax® (alendronate sodium) was spelled incorrectly, the strength was denoted in grams instead of milligrams and the patient's name was omitted. Other errors can occur when the clerical staff is unfamiliar with a drug, such as when a physician gave a verbal order for methotrexate to be given weekly, and it was called into the pharmacy as daily.
Since there has been no action taken by the office manager, the nurse might present her concerns and ask for help from her hospital's patient safety officer. Changing the way "things" have always been done is difficult, but she will have to decide whether it is worth the energy, or it is time to look for a new position.
Hedy Cohen, MS, BSN, RN
A: The RN should state her concerns in writing to her manager. Clearly documenting the two concerns without subjectivity is important. If a professional perspective is maintained, it fosters the clinical management team to objectively assess the problems.
The written statement by the nurse describing her concerns should include any potential solutions to correct the problem. Perhaps the nurse has evaluated that the clinic requires an extra part-time nurse during peak hours to perform the tasks related to orders and prescriptions. She should cite the hours and if this would potentially impact on the need for the current clerical staff.
The nurse should request an appointment to discuss the situation with the manager, acknowledging these concerns have been voiced in the past. An appropriate oral introduction and effective way to direct the manager's attention to the seriousness of these concerns would be a statement by the nurse that she understands she is professionally liable if she does not report a violation of the Nurse Practice Act.
Therefore, in good faith, she is identifying to her manager the issues she believes constitute unlawful conduct. The nurse can explain that she now has documented the issues she previously reported orally, to enable the manager in taking this forward to her supervisors.
The nurse can conclude the meeting with her willingness to work with the manager on any processes to change the current clinic practices, but indicate that if things do not change in the next 2-3 weeks, she will have no alternative except to notify the hospital administration that has ownership of the clinic.
Barbara Weber Berry, MSN, RN
This Issue's Q & A Panel
Arlene R. Caselli is staff nurse, Our Lady of the Resurrection Medical Center, Chicago. Hedy Cohen is vice president, Institute for Safe Medication Practices, Huntingdon Valley, PA. Barbara Weber Berry is vice president, patient services, VNA Home Care of Mercer County Inc., Trenton, NJ.