NR 506 Discussion Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study

What are the potential ethical and legal implications for each of the following practice members?

-Medical assistant

The medical assistant works in outpatient, ambulatory care facilities, and medical offices, working with physicians to perform administrative and clinical duties. They are responsible for obtaining medical histories, explaining treatments or procedures to patients, assisting during patient examinations, collecting lab specimens, EKGs, phlebotomy, preparing and administering medications. Administrative duties include computer use, filing, coding, scheduling appointments, and insurance authorizations (AMA, 2023). On a national level they can perform these duties but cannot write prescriptions, treat patients, diagnose, or use other providers’ information to prescribe. This is considered illegal activity and what Stephanie did was unacceptable. As a medical assistant Stephanie is supposed to keep patients safe and she acted outside of her scope of practice. She treated a patient with a medication- Amoxicillin, that she could have mistakenly worsened the patient condition, caused an allergic reaction, inappropriately dosed the patient, and caused irreparable harm to the patient, all while using the NPs information to illegally prescribe that medication. Stephanie could be terminated from her position, lose her medical assistant license, monetary penalties, or face jail time for impersonation of a nurse practitioner. An advanced practice nurse is a person who holds certification in accordance with section 8 or 9 of P.L.1991, c.377 (NJ Division of Consumer Affairs, 2020). Not to mention that if the patient were harmed the medical assistant could face a lawsuit for impersonation of a provider and unintentional harm to a patient. This is unethical as the medical assistant is practicing medicine illegally.

-Nurse Practitioner

The nurse practitioner in this scenario is at risk of losing her license, being involved in a lawsuit, and facing other damages. A national provider identifier (NPI) acts like a social security number, allowing the provider to prescribe medications and place orders. It is dangerous to prescribe medications without seeing your patient and assessing them. In this case study the NP had no idea that the medication was being prescribed to Mrs. Smith without her authority. Although this was fraud, it could become difficult to prove that the prescription was given by Stephanie and not the nurse practitioner. Stephanie committed fraud and theft by using the NPI number of the nurse practitioner and acting outside of her scope of practice. According to Capozzola et.al., 2018) there was a similar situation where a physician prescribed a narcotic and muscle relaxant to a patient without seeing the patient prior to prescribing. The patient had a heart condition and ended up drinking before taking both the medications. The provider who did not see the patient never had a chance to do a workup or assess the patient. The patient involved expired with an autopsy performed, which indicated the cause of death was due to cardiac reasons, drug, and alcohol toxicity. The patient’s daughter sued the physician for negligence and medical malpractice resulting in wrongful death (Capozzola et.al., 2018). This is just an example of what can happen when medications are prescribed unsafely.

-Medical Director

The medical director can face a lawsuit due to patient harm, fraud, and theft. This is the first time that someone caught Stephanie using an NPI number to prescribe medication, act out of her scope of practice, impersonate a provider, and practice medicine illegally. The case study doesn’t reference whether she has done this before or if the patient experienced any harm. The issue is Stephanie is aware of her role, ethics, and her scope of practice, yet she still acted unethically. The medical director will have to decide to protect the practice and its employees. There will need to be a decision about pressing charges for violating the law, impersonation, and fraud. Stephanie will most likely be terminated and could face legal charges.

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-Practice

The practice is at risk of malpractice, especially if this patient was harmed or if Stephanie has done this before. This is a serious situation. Prescribing the wrong medication is considered negligence and there is a reason why an individual needs extensive education and to pass the boards prior to being able to prescribe medications. In the case study introduced by Capozzola et. al. (2018) the patient’s daughter sued the physician and the practice for patient harm, negligence, and malpractice. In that situation she didn’t win the lawsuit because the patient was educated on the medication and side effects. In these situations, a practice can face harsh monetary penalties, settlements in favor of the patient, and possible close down. The practice will have to take extreme measures to prevent this situation from occurring. Although Stephanie is knowledgeable and was considered an asset, she has become a liability risk for the practice. She will most likely face termination for what she did. To prevent these issues from happening again, the practice will need to enforce new policies restricting employees.

What strategies would you implement to prevent further episodes of potentially illegal behavior?

In order to prevent potentially illegal behavior, it is important to understand each individual’s scope of practice and have an appreciation for the code of ethics; doing no patient harm. The practice should hire people with a clear understanding of their role and a commitment to core values evolved from the code of ethics. Recommendations include recruitment of staff that embrace core values of medicine, practicing compassion, re4specft for patient autonomy, competence, and caring for all patients. Educate leaders to create a professional integrity culture within the practice (DuBois et. al., 2018). Through establishing a practice culture, everyone has a clear understanding of professional standards and expectations. Increase oversight from providers on colleagues to prevent mistakes. It is important for staff to work independently but they should be supervised by higher ups to ensure patient safety, adherence to practice policies, and ethics. Tracking serious errors and placing consequences is important to avoid situations where staff work outside of their defined scope of practice. Tracking consequences enables evaluation by state boards and other disciplines (DeBois et.al., 2018).

What leadership qualities would you apply to effect a positive change in the practice?  Be thinking about the culture of the practice.

Leadership is one of the most important qualities in a medical practice because it defines a standard and helps in the development of a culture. Leading through example can show other staff members the way they should act, interact with patients, handle patient concerns, and follow policy. Center for Creative Leadership (2023) explains that there are 3 Cs of change- Communication, Collaboration, and Commitment. Communication through successful leadership is about understanding organizational values, urgency for change, and the explanation of benefits directing people to embrace a positive change. Collaboration unites people in working toward change. Leaders work with employees to cross boundaries and remove unhealthy competition. Employees should be included in decision making processes early on and commit to the change process. Commitment made through successful leadership is conveyed through support in the change, stepping outside of comfort zones, and embracing common values shared within the facility (Center for Creative Leadership, 2023). It isn’t easy to enact change, especially when a practice has been doing things the same way for a very long time. Having a strong leader capable of listening, understanding, and presenting the way is important to creating change. People are scared of changes and may remain reserved, but a successful leader will guide them and find ways for them to be involved in decision making.

Reference:

AMA. (n.d). What is a Medical Assistant. Retrieved 2023

Capozzola, Jamie Terrence, & Lynch, M. (2018). Physician Defeats Liability for Prescribing Without In-person Consultation. Healthcare Risk Management, 40(8).

Center for Creative Leadership (2023) How to Be a Successful Change Leader. Retrieved https://www.ccl.org/articles/leading-effectively-articles/successful-change-leader/

DuBois, Anderson, E. A., Chibnall, J. T., Diakov, L., Doukas, D. J., Holmboe, E. S., Koenig, H. M., Krause, J. H., McMillan, G., Mendelsohn, M., Mozersky, J., Norcross, W. A., & Whelan, A. J. (2018). Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group. Journal of Medical Regulation, 104(4), 23–31. https://doi.org/10.30770/2572-1852-104.4.23

NJ Division of Consumer Affairs. (2020). NJ Board of Nursing Statutes. Retrieved https://www.njconsumeraffairs.gov/Statutes/nursing-law.pdfLinks to an external site.

I found the video very helpful and informative. I didn’t know about the different types of malpractice insurance offered to nurse practitioners and going into the field, it may have been something most people would overlook. If employers offer claims made insurance instead of the occurrence insurance, if you don’t know better, you might just accept what they are offering without any negotiation for a tail or extended coverage. I decided to research further and found a retrospective cohort study involving medical malpractice claims taken from the Comparative Benchmarking Database. This database contains approximately 30% of United States claims (Myers et.al., 2021). When reviewing the claims in the study, claims involving APRNs were more likely to be paid on behalf of the defendant when compared with physicians, but they were usually paid out by the hospital or practice. APRNs usually work alongside physicians and the study indicates that APRNs are not usually named in claims due to allegations of surgical harm. Laceration was one of the largest malpractice claims filed accounting for 2,910 claims (Myers et.al., 2021). APRNs are also less likely to be named in claims involving diagnosis-related allegations, and the authors of the study feel this may be attributed to the fact that APRNs see less complex, lower risk patients when working without physician supervision (Myers et.al., 2021). Many APRNs work for hospitals, facilities, and private practices, so when malpractice claims are filed the employer usually pays the defendant (Myers et.al., 2021). This makes the video clip you provided even more valuable because it is important to know ahead of time what type of malpractice insurance your employer will be carrying.

Reference:

Myers, Sawicki, D., Heard, L., Camargo, C. A., & Mort, E. (2021). A description of medical malpractice claims involving advanced practice providers. Journal of Healthcare Risk Management, 40(3), 8–16. https://doi.org/10.1002/jhrm.21412

Thank you for sharing this video. I found it to be beneficial and Carolyn Buppert to be very knowledgeable. That way she explained what how one malpractice insurance policy was better than another was straightforward and easy to understand. Occurrence malpractice insurance is a much better option because once the payment is made for the year, you are covered anytime a lawsuit is filed. Even if the claim is made years later and you no longer work at that practice or have that insurance. In comparison, “claims made” require payment every year to be covered. There is an option to buy coverage Buppert mentioned called tail coverage. She recommended negotiating this aspect of our employment. If the employer has claims made insurance, then we should ask about tail coverage and get it in writing. It is always better to get an occurrence malpractice policy and make all premium payments (Buppert, 2017).

This video was extremely helpful. Thank you for sharing it with us and I started to follow her on YouTube.

Carolyn Buppert. (2017). Malpractice insurance for nurse practitioners: Claims made or occurrence? [Video]. YouTube. https://www.youtube.com/watch?v=jL1FLrq2SGY

I currently work for a health system in the Chicagoland area where I travel to different ERs based on their needs. I have observed many leadership issues when other nurses discuss problems with the ER and administration. Having good leadership is so important, like you explained. It is a foundation for the rest of the team and can even help build morale when times are tough. For instance, one of the hospitals that I am currently rotating to is seeing a mass exit of their ER nurses. There are about 10 nurses leaving between agency, staff, and internal floating pool. You can’t help but wonder why? When you take a step back and look at the bigger picture you see how overworked and burnt out these nurses are. Leadership has failed them. When staffing is tight on the units, they are able to cap off and say no more patients to the ER. However, the ER has no “cap”. The ER doors are always open! These nurses never get a break, and are often handling 6-7 patients including psych, acute ER, and inpatient holds. In cases like this is where leadership should step in, and provide change but they have not. Like you mentioned, having a leader that can take feedback, listen, bring about change is crucial in healthcare. Unfortunately, the leadership at this hospital is not able to do any of that for its staff and thus are seeing a mass exit.

Medical Assistant

Cross-trained medical assistants are only capable of performing clinical and organizational tasks. As a result of the lack of prescriptive authority, Stephanie, the medical assistant, was practicing beyond the scope of her training. There is a violation of both federal and state laws (AAMA 2019). Patients should be treated with nonmaleficence by a medical assistant. Medical assistants are responsible for keeping patient records, collecting data, and collecting lab specimens in primary care settings. Based on both an ethical and legal perspective, Stephanie behaved outside her field of experience in the case study. Because Stephanie made a medical decision without having the appropriate medical or nursing experience to prescribe amoxicillin to Mrs. Smith, she committed immoral acts that may have resulted in unintended patient damage and maleficence. The nurse practitioner’s license was used to treat Mrs. Smith by Stephanie who impersonated a nurse practitioner, forged the APRN’s signature on the script, and abused her diagnostic and prescriptive powers. In the state of Illinois, Stephanie may be terminated or revoked for her actions, pay monetary penalties, spend time in prison, and be unable to work as a medical assistant (Illinois Department of Financial and Professional Regulation, n.d.).

Nurse Practitioner

Medical Assistant Stephanie’s improper use of authoritarian power has now presented an ethical dilemma for the nurse practitioner. This would therefore constitute malpractice, with legal and ethical repercussions for the nurse practitioner. A nurse practitioner faces legal repercussions for not practicing justice in this case. She should discuss her concerns with her and decide how to handle the situation. It is unknown whether Stephanie knew about the danger she was putting the patient in and she has put the NP profession at risk. A nurse practitioner has an ethical obligation to assess the patient’s condition and choose the appropriate medication before deciding on drug treatment. Liability for negligent supervision is one of the legal consequences for the nurse practitioner (Illinois Department of Financial and Professional Regulation, (n.d.)). When a nurse practitioner forges a prescription on their behalf, they are morally and legally responsible for informing the medical assistant. The NP may be sued for malpractice and/or negligence. The nurse practitioner’s treatment falls short because the patient was not assessed until he was prescribed amoxicillin. We don’t know if the patient needed amoxicillin. The patient was not harmed, according to the case report. If the patient was not harmed, the NP might be charged with neglect rather than malpractice.

Medical Director

It will be an ethical dilemma for the Medical Director to decide how to deal with the problems. Despite the fact that the patient was in danger, it’s not stated whether or not the situation impacted the patient. Stephanie’s medical assistance was not harmful, and the next question is whether it should be reported or handled in the clinic (Weiss, 2022). The Medical Director may be penalized for violating state and federal laws. In the event that a patient was injured or died, a lawsuit would be filed against the organization, the NP, and the Medical Assistant. It is possible that fraud charges are based on reimbursements for services that did not take place.

Practice

Medical assistants must be disciplined, such as termination and legal action, to avoid the recurrence of this incident. An unethical act could result in the practice being closed if a certain number of complaints are filed with the medical board. Furthermore, ethical issues arise regarding information disclosure and mandatory reporting, as well as patient safety implications. There is a sense of moral obligation associated with medicine prescriptions in this practice. To minimize medication errors and ensure the safety of patients, appropriate technologies should be used, such as prescribing software and electronic drug references.

In order to determine the reason Stephanie prescribed Mrs.Smith medication, the first step would be to investigate thoroughly. If an illegal situation arises, such as this one, I will implement a policy. All members should be reminded to review their guidelines and job descriptions. The scope of practice for each employee will be reviewed and explained in meetings with all employees. At that point, I will follow up with all employees to ensure that their understanding has been conveyed properly. An employee will be retrained if he or she needs help understanding. It will be inspected periodically to see if the work environment is conducive to productivity. Every employee will be able to see and read the policies displayed around the office. In order to prevent a similar incident from happening again, a protocol would be developed based on ethical and legal guidelines. If someone breaks the rules, disciplinary action will be taken (Atkinson, 2019). By leading by example, I would be able to effect a positive change in the practice. In my role as a role model, I will set an example of positive behavior. Respecting all staff members and communicating effectively would be my top priorities. I would also actively listen to all member’s concerns. As part of my efforts to establish a culture of accountability for all actions and failures within the practice, I would also consult with the team about future decisions (Aboramadan & Dahleez, 2020).

References-

AAMA. (2019). Disciplinary Standards and Procedures. Disciplinary standards and procedures. aama-ntl/cma-aama-exam/faqs-certification/disciplinary-standards.

Aboramadan, & Dahleez, K. A. (2020). Leadership styles and employees’ work outcomes in nonprofit organizations: the role of work engagement. The Journal of Management Development, 39(7/8), 869–893. https://doi.org/10.1108/JMD-12-2019-0499

Atkinson. (2019). Preparing physicians to contend with the problem of dual loyalty. Journal of Human Rights, 18(3), 339–355. https://doi.org/10.1080/14754835.2019.1617121Links to an external site.

Nurses. (n.d.). https://idfpr.illinois.gov/profs/nursing.html

Weiss. (2022). Duty to Report Incompetent Physicians. American Family Physician, 106(4), 450–452.

In the video, nurse practitioners are shown as leading the charge and forefront of healthcare. I agree that nurse practitioners should be diagnosing, assessing, and prescribing for the patient. Adopting the full scope of practice for nurse practitioners is associated with improved access to care (Kandrack et al, 2021). Having an increase in the capacity of nurse practitioners to work can help provide better and easily accessible care for the population. Nurse practitioners are trained to be leaders and follow instructions from physicians.

Kandrack, Barnes, H., & Martsolf, G. R. (2021). Nurse Practitioner Scope of Practice Regulations and Nurse Practitioner Supply. Medical Care Research and Review, 78(3), 208–217. https://doi.org/10.1177/1077558719888424

I enjoyed reading your remarks. One statement that caught my attention was the proposal that this situation might be dealt with within the clinic rather than reported to the licensing board. I read the Weiss (2022) article that you cited as well. The decision to admit to errors or cover them up can make one pause for consideration in the clinical setting. Tigard (2019) writes on the importance of moving from a “culture of blame,” to a “culture of safety.” A few months ago, I made a medication error and almost immediately realized the mistake I made. I reported my error to the doctor and wrote an occurrence form on the incident. This was a humbling but not humiliating experience; the patient did not experience harm and the doctor had an appropriate and calm response. While the case study with Stephanie is a slightly different story than my experience, and encourages us to consider these ethical dilemmas.

You also mentioned that this could potentially be seen as insurance fraud if they charged for services that were not provided. This also sparked my interest, and I did some digging. I read a really interesting article about prescription fraud and recent changes to autofills and autorefills due to problems with Medicare and Medicaid (Hayes, 2022). I cited it below so you can access it through our library.

Tigard, D. W. (2019). Taking the blame: appropriate responses to medical error. Journal of Medical Ethics, 45(2), 101. https://doi.org/10.1136/medethics-2017-104687Links to an external site.

Hayes, S. A., (2022). The Three Most Misunderstood Words in Health Care: Fraud, Waste and Abuse. Benefits Quarterly, 38(4), 15. https://chamberlainuniversity.idm.oclc.org/login?qurl=https://%3A%2F%2Fwww.proquest.com%2Fscholarly-journals%2Fthree-most-misunderstood-words-health-care-fraud%2Fdocview%2F2738609466%2Fse-2%3Faccountid%3D147674

I agree with you that new policies need to be made and employees should understand the scope of practice for their roles. I just don’t feel that policy alone corrects the situation with what Stephanie did. When you go to school to become a medical assistant (which I did) they tell you what you are allowed to do, defining your scope of practice for your state. Stephanie had an idea of what she was doing and did it without even consulting with the NP. I am not trying to be harsh but look how hard we are working to get our NP license and imagine losing it over something you had no control over. A mistake in diagnosis or medication prescription can cause wrongful death to a patient. Situations like that carry punishments like malpractice claims, loss of licensure, and jail time. An example by Buppert (2018) is an incident in 1996 where a NP miscalculated a medication dosage for an infant, an RN gave the wrong dose to the infant, and the infant died. The local prosecutor learned of the case and prosecuted them for criminally negligent homicide, in which they accepted a plea agreement (Buppert, 2018). At least 1 NP has lost their license and gone to jail for filling out a pre-signed prescription. According to Title 21; Code of Federal Regulations, Section 1306.05 prescriptions shall be dated as of, and signed on the date issued, bearing the full name and address of the patient, drug name, strength, dosage form, quantity prescribed, directions for use, name, address, and registration number of the practitioner (Buppert, 2018). In this situation if something happened to the patient the NP could be held responsible because her name is listed as the prescriber. She only found out because the patient happened to come in, but how many other patients were prescribed medication without consultation from the provider. The practice has too much of a laissez-faire attitude if situations like this are arising. I would question how the medical assistant had access to the NP provider number in order to prescribe. Secondly, I would want to know how the medication was prescribed via paper script or electronic. Are the prescription pads locked up like they are supposed to be? Does the office computer system allow for electronic prescription without input of the NP information and provider number. There are obviously many questions and concerns regarding how this practice is running. Although Stephanie is wrong, she may have uncovered a huge issue within the practice. Depending on the investigation and whether Stephanie has done this before, should indicate her punishment. I think in most cases she would be terminated because of the increased risk of malpractice she imposed upon the practice.

Reference:

Buppert. (2018). Can a Nurse Practitioner Go to Jail for Malpractice or Other Things Done in Clinical Practice? Journal for Nurse Practitioners, 14(6), 503–504. https://doi.org/10.1016/j.nurpra.2018.04.001

NR 506 Discussion Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study