NR 510 Week 4 Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study Part Two Discussion

Like I stated in Part 1, this can be a serious matter even if the patient is not physically harmed. Since Stephanie is the medical assistant, placing and verifying orders are not in her job description. Even as I am now as a bedside nurse, placing orders without proper verification from a MD/NP/DO would land me in some trouble if this happened.Only nursing orders, like IV pump, heating pad or basic equipment/care can be placed by the nurse at the hospital I work at.

As an NP in this situation, I do not think that the NP is held liable. If a nurse places an order and document that it was verified by the MD, but thru investigation it was found that it was not, the MD is not held liable. The same should go for the NP. The nurse would be reprimanded for doing that and the MD will not held liable or be found at fault. In school for each profession, one is taught what they can and cannot do within legal limits. Stephanie got comfortable and thought it was go to go outside of her job description that I am sure she already knows. The practice as a whole may be liable, especially if harm was done to the patient. The principle of non-maleficence (to do no harm) states that a health care professional should act in such a way that he or she does no harm, even if her or his patient or client requests this. Stephanie may have not had bad intent and was thinking she was probably helping in this situation to alleviate some of the work for the providers and NPs. Also, she probably thought she was making it more simple for the patient. However, this could cause harm to the patient as a NP or MD must assess if and why a new antibiotic must be ordered in the first place. Also, the practice is responsible and must be held liable of alerting Mrs. Smith of the situation so the he knows what he going on. This maybe the hardest part as Mrs. Smith might lose trust in the practice, place a bad review and can have the right to sue the facility even if no physical harm was done. Negligence can be seen as failure to take reasonable care or steps to prevent loss or injury to another person. Nursing negligence is when a nurse who is fully capable of caring does not care in the way a reasonably prudent nurse would, and as a result the patient suffers unnecessarily. Even though this was not directly a nursing issue, she can still sue for negligence. Mrs. Smith may do nothing at all once told if she feels strongly tied to the practice. However, it is completely up to Mrs. Smith how she wants to go about the issue. If she decides to take it that far into suing the practice, Stephanie might be at risk to lose her job as she now becomes a liability to the practice. There is many ways this situation goes depending on the outcome. (Tinnon, 2017)

To prevent that issue, maybe the medical assistant can only have access to certain parts of the program. For example, maybe when it comes to prescriptions, the medical assistant can not print out or issue it out to the patient till the NP/MD signs off and verifies it. The program should stop her from issuing it to the patient without proper verification. For example, in the hospital setting, even if the program is the same name, each profession has their own set customized for their job description. A nurse’s screen will look different from a PCA, unit secretary or a respiratory therapist. With this setup, one can only access what is felt is allowed for the specific job description. (Schub & Kornusky, 2016)

Reference:

Schub, T. B., & Kornusky, J. M. (2016). Standing Orders, Order Sets, and Protocols: Government Regulations. CINAHL Nursing Guide,

Tinnon, E (2017). Situational awareness and Nursing Code of Ethics. Nurse Educator, 43(1), 32-36.

In this weeks reading, we learned about the legal scope of nursing practice and how to solve ethical dilemmas. Thankfully Stephanie was honest and admitted what she did. In a healthcare dilemma that is probably seen far too often, Stephanie was in the wrong for assuming the prescription was ok without consulting me. Patients can be pushy, but Stephanie could have either set Mrs. Smith up with a same-day appointment, have her come in a day or two to be seen early, or at least checked with the on-call physician or Nurse Practitioner in the practice to see if the prescription was ok. The first legal concern is a medical assistant prescribing. The role of a Medical Assistant is to escort patient, take vital signs, and write down the chief complaint in the medical record (Chapman & Blash, 2017). Prescribing is outside of her scope of practice. The ethical dilemma is reporting a hard-worker or not for trying to help you out. This may be her first offense, but she should know better, especially with ten years experience, that she was acting outside her job description. Telephone prescribing is risky due to lack of physical assessment, testing for infections, and the possibility of over-prescribing antibiotics (Ewen, Willey, Kolm, McGhan, & Drees, 2015). An antibiotic for a cough is probably useless and could potentially lead to yeast infections or lead to antibiotic-resistant infections, doing Mrs. Smith more harm than good. I am liable for this situation because my name is on the prescription, and any harm to the patient could be a negligence or malpractice suit. I should also follow up with all of my patients and their symptoms. I also need the correct coding and documentation for billing purposes. Things need to be appropriately documented. Depending on the state of practice and the ability of the physician to delegate NPs to prescribe, the practice could also be seen liable. The practice should also oversee the hiring and firing of employees as well as making sure people are in their scopes of practice. A good way to safeguard my role would be to not prescribe via telephone. Although more time consuming, physically assessing my patients and testing for illness before I prescribe medications is safer for my license and my patients.

Chapman, S. A., & Blash, L. K. (2017). New roles for medical assistants in innovative primary care practices. Health Services Research, 5(2), 383-406. doi:10.1111/1475-6773.12602

Ewen, E., Willey, V. J., Kolm, P., McGhan, W. F., & Drees, M. (2015). Antibiotic prescribing by telephone in primary care. Pharmacoepidemiology And Drug Safety, 24(2), 113-120. doi:10.1002/pds.3686

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On a basic/standard level of ethical legal concerns, no medical professional should be doing anything in representation of another provider;this should be well known to all medical professionals. It’s as basic as not giving someone your badge to take a blood sugar, common practice learned day 1. As a medical assistant Stephanie should have known this was wrong, she knows she shouldn’t document under another provider and is fully aware she can not decide which medication a patient needs, only a refill of a prescription which is authorized by the provider whose name will be on the prescription.

As the provider who “prescribed” the medication it is my responsibility and liability if this was the wrong medication, the patient has an allergic or any adverse reaction because Stephanie was unaware of the patients allergies or other condition/medication that may interfere with the new medication. Talking more severely, had this been the wrong medication and adverse/serious reactions had resulted for the patient there may not have been a way to determine who had called in the prescription, leaving the NP open for a legal repercussions or medical malpractice(Buppert, 2015). This is one of many reasons functioning within ones scope of practice is pertinent daily life as an NP. Liability for the practice is high because if something had happened it would not only come back to the NP but the practice as you are a practice employee.

As far as quality improvement for now you could call in your own prescriptions and refills but long term this is not time efficient. The practice should hold a class or informational session required for anyone ordering prescriptions as well as a policy put into place for medical assistants to follow strictly in this role if they are going to have the responsibility of sending in medication refills. Another solution is that they could enter it but it has to be signed off by the NP, which is also time consuming for an NP daily schedule. In conclusion there are many alternatives other that what Stephanie chose and there needs to be serious education put into place.

Buppert, C. (2015). Nurse practitioner’s business practice & legal guide (5th ed.). Retrieved from https://bookshelf.vitalsource.com

Sorry, it seems I had begun answering this in my other post of part 1 of this question!

There are ethical-legal considerations in this situation, as Stephanie’s actions were outside her scope of practice. Additionally, if any harm came to the patient in any way, any blame and legal actions would be placed against the licensed prescriber (in this case the liability would lie in myself as the NP). I would have to speak with Stephanie about her actions. I would tell her I understand that patient’s can be persistent at times, however she should have taken a message with the patient and told her she would call her back, and then discuss the situation with me first. I may have still allowed for a prescription to be phoned in, but it would be up to my digression to do so, and would not only at least be aware of the situation, but be able to treat it accordingly.

According to Goldberg )2014), every act performed by a physician, is not necessarily counted as practicing medicine. Courts concede that certain duties such as administering injections, drawing blood, or changing bandages may be performed by non-physicians, however, courts find that diagnosing and treatments such as prescribing medications, is considered crossing the line into the practice of medicine. I would have to explain to Stephanie that her actions not only put the patient at potential risk of harm, but she also placed me at legal risk as well. I would ask her to never again put me in that position, and to please come to me with patient issues, even if it is something that she doesn’t think I would mind doing for the patient. I would make it politely clear that this can never happen again, under any circumstances. She needs to always speak with the licensed prescriber before phoning in any medications of any kind, for any patient.

Goldberg, D. (2014). My ‘medical technicians’ are unlicensed. What is my crime?. Dermatology Times, 35(9), 12.

I like to see how people are having different reactions and opinions to this topic. Some say that she may be fired or some would say that his would be a write up and not to happen again. I stated that all these outcomes can happen depending on the outcome. This to me would be like when a nurse mislabels a specimen and places the wrong label on it. This is extremely dangerous as the wrong blood on the wrong patient can cause great harm to the patient. However, nowadays, many safety guards are put in place to decrease the chance of this happening. Some hospitals react differently depending on the outcome. However, this issue can also be reported to the State Board, possible suspension/loss of license, loss of job, and even have the nurse sued. The nurse may also just get written up and may be able to keep her job. However, in many cases I have seen, especially if the lab was stopped before posting it on the program, the nurse is strongly warned and is written up. I have seen where they fired a nurse for mixing up glucose results. This would be almost impossible at the facility I work at as AccuCheck machines links to the patient and only lets you gain a glucose reading once the employee has scanned the correct patient. In a textbook explanation, she would get written up, reported to the state, and possibly lose her job. I have also seen a nurse, after several warning, get fired for placing orders in the computer without proper verification from MD. He was fired from a prestigious, well-known hospital, however, he was able to get another job. However, he could have easily been reported to the board and lost his license. It all depends on the outcome of the patient and how the facility chooses to handle this situation. In reality, regardless of what I believe or know should happen in this situation, she would probably just get seriously warned and written up and/or fired and find a job elsewhere.

Stephanie has been with the practice 10 years and feels confident she is knowledgeable enough to prescribe medications for certain illnesses due to her familiarity with patient care and commonly prescribed medications for certain illnesses, etc. However, she was not authorized to take Mrs. Smith’s prescription renewal request without Mrs. Smith being seen by the physician, myself, or another staff NP. The order for the prescription should have come from the physician, another NP on staff, or myself not an “insistent” patient who is not qualified to determine which illnesses are treatable with antibiotics or if she even needed an antibiotic. Even though my name is on the label as the prescriber, I am exempt from any liability due to my name being forged by Stephanie. According to the law, Stephanie’s actions must be reported to the authorities, which is the first step in clearing my name. Federal law states that prescription medications may only be written by licensed health care practitioners who have also received training in medication management and patient assessment (Singh et al., 2013). Each state has precise legal codes that require or permit health care providers to disclose a patient’s health information for the purposes of reporting a crime (Singh et al., 2013). The physician in charge has a legal and ethical responsibility to train employees about the laws that prohibit unauthorized persons from writing prescriptions. Stephanie has been at the practice so long that she has gotten comfortable with making decisions without consulting the physician or the NPs. Her actions are dangerous to the patient’s health, her career and those of her colleagues, and the future licensing of the practice. Any attempt to fill or write a forged prescription is a violation of federal statutes; the violating person is perpetrating a crime (Singh et al., 2013). I hate to be so dogmatic about it, but my license and professional reputation are at stake.

Numerous states have established laws that prosecute those who forge prescriptions (Singh et al., 2013). An example of such a law is the one posted below that was passed by the California legislature, which states prescription forgery is a violation of Business and Professions Code 4324 (Singh, 2013):

DIRECT WORDING from Singh et al., 2013

(a) Every person who signs the name of another, or of a fictitious person, or falsely makes, alters, forges, utters, publishes, passes, or attempts to pass, as genuine, any prescription for any drugs is guilty of forgery and upon conviction thereof shall be punished by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code or by imprisonment in the county jail for not more than one year.

(b) Every person who has in his or her possession any drugs secured by a forged prescription shall be punished by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, or by imprisonment in the county jail for not more than one year.

Reference: Singh, N., Fishman, S., Rich, B., & Orlowski, A. (2013). Prescription opioid forgery: Reporting to law enforcement and protection of medical information. Pain Medicine, 14(6), 792-798. Retrieved from https://doi.org/10.1111/pme.12062

The medical assistant’s actions raise several ethical-legal concerns because she broke several laws. She is not authorized to write prescriptions under her scope of practice. Medical assistants are to work directly under the primary care provider (Chapman & Blash, 2017). If the patient had developed an allergic reaction to amoxicillin, the practice could have been sued. Patients can be difficult to handle, especially when they feel hey know what’s best for their health. I understand and value that Stephanie just wanted to help, but her actions put the practice, the patient’s health, and my license at risk. As nursing students, we receive extensive training about our scope of practice and laws governing what we can and cannot do. It is safe for me to assume that Stephanie has done this before since she has been at the practice for 10 years. The medical assistants in the office need to undergo staff training about scope of practice and policies regarding patient interaction. Stephanie should face disciplinary action, which may affect her ability to work as a medical assistant. The ethical dilemma is that the physician or myself will have to report a co-worker when she was only trying to assist. On the other hand, Stephanie is a veteran medical assistant. She should have known that she was acting outside of her scope of practice. All she is authorized to do with patients is to take vital signs and write down the health complaint of the patient (Chapman & Blash, 2017). The medical ramifications of her actions put the patient at risk. Prescribing medications over the phone pose a great risk to a patient’s health because the patient has not been tested for infections or been given a physical assessment (Ewen et al., 2015). Stephanie obviously did not know that prescribing an antibiotic for a cough was useless, and she put the patient at risk for developing a yeast infection or resistance to the antibiotic. I do not believe I am liable because Stephanie used my name without my consent. This could also be considered identity theft. The practice is liable because it employs Stephanie and must report her actions to clear up any legal action that will affect me or the livelihood of the practice in the future. Stephanie may be a good employee, but I believe she knew the legal ramifications of using my name. Her actions pose ethical concerns. She should never misrepresent her role, scope of practice, or assume the role of another provider (Chapman & Blash, 2017). In the future, the office may establish a policy that requires NPs to call in their own prescriptions for patients. The office can also establish a sign-off rule in which the NP and physician must sign a prescription order.

References:

Chapman, S. A., & Blash, L. K. (2017). New roles for medical assistants in innovative primary care practices. Health Services Research, 52(S1), 383-406. Retrieved from https://doi.org/10.1111/1475-6773.12602

Ewen, E., Willey, V. J., Kolm, P., McGhan, W. F., & Drees, M. (2015). Antibiotic prescribing by telephone in primary care. Pharmacoepidemiology And Drug Safety, 24(2), 113-120. Retrieved from doi:10.1002/pds.3686

There are a few ethical-legal concerns associated with this situation. First, as I mentioned in part-one discussion, regardless of the years of experience, she is still a medical assistant and it is not within her job description nor is it legal or ethical for her to prescribe any medication to a patient. In this situation, because my name was on the ordered prescription, the liability for me is great however, this is a great liability for the practice as well. According to Woten and Karakashian (2018), APRN hold the prescriptive authority. There are several improvement strategies that can be implemented as an APN to safeguard my role and assure patient safety. The first action that I would take would be to call the patient in for an assessment and evaluation including blood work. After ensuring the safety of the patient, I would then take disciplinary action against the nurse assistant for her unlawful actions to make sure that the practice policy and regulations are understood. According to Heering and Karakashian (2017), a disciplinary action against an employee involve an implementation of a systematic process for managing undesirable employee behavior that is observed to be a threat to the attainment of organization goals and/or the maintenance of public safety. I don’t mean to come off too strong or even over the top, however I personally feel this is a major concern which could have done harm to the patient. The safety of my patient are so important and a top prior to me and such an action that the medical assistant carried out could have caused great harm. So to ensure that such an action is not carried out I believe that these measure should be carried out.

Reference

Heering, H. C., & Karakashian, A. B. (2017). Employee Disciplinary Action: Conducting. CINAHL Nursing Guide,

Woten, M. B., & Karakashian, A. B. (2018). Advanced Nursing Practice and Prescriptive Authority. CINAHL Nursing Guide,

There are a few ethical-legal concerns with this situation. Stephanie has practiced outside of her scope of practice by calling in a prescription without speaking with a physician. She has forged documentation by doing this as well. According to the Centers for Medicare & Medicaid Services, fraud is “the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person (Curtin, 2014). Stephanie has given a prescription intentionally. Not only that, the patient was never examined by a provider. There could have been more wrong with Mrs. Smith other than just a “cough”. The patient needs to be fully examined before any medications are prescribed.

The liability of this situation lies on both Stephanie and the practice. First off, what has happened needs to be reported to the patient. Mrs. Smith needs to be aware that what was done was wrong, and that no provider ever permitted that prescription to be written. The pharmacy also needs to be notified. Lastly, the nursing board needs to be notified of Stephanie’s practicing outside of her scope of practice. She can potentially lose her license over this situation.

A meeting should be held with the other nurse practitioners and physician. As a group, we need to be sure that each of the med aides is aware of their role and their scope of practice. Education needs to be done frequently.

The liability that falls on both myself and the practice is the potentially of being sued. Unfortunately, having nothing to do with this situation occurring, we are both still liable. Stephanie is hired and working underneath me in the practice as one of my staff members.
Curtin, L. (2014). Documentation: You’ve got a lot to lose. American Nurse Today, 9(9). Retrieved from https://www.americannursetoday.comLinks to an external site.

According to the American Association of Medical Assistants (AAMA) Stephanie violated the standards of practice for a certified medical assistant and the incident should be reported in writing to the AAMA. Legally and ethically you would have the responsibility to report her, I would think that she violated company policy as well. The decision of disciplinary action regarding her certification would be made by the Certification Director of the AAMA. If the patient had an adverse reaction from the medication that was order, negligence could be accused and there could be legal action taken against the provider that the prescription was written under, the medical assistant that put the order in, and the facility that employed both (Brent, 2018). To prevent this problem from happening in the future, a policy should be put in place where all providers must co-sign on the prescription orders before they are transmitted to the patient’s pharmacy. The use of electronic medical records may present the opportunity for those without prescriptive authority to do so. Policy must be put in place to prevent these occurrences to prevent license revocation as well as preventing payment for the prescriptions (Brent, 2018).

Resources:

America Association of Medical Assistants. (2018). AAMA disciplinary standards and procedures for CMAs (AAMA) and examination candidates. Retrieved from http://www.aama-ntl.org/docs/default-source/cma-exam/disciplinary-standards.pdf?sfvrsn=10Links to an external site.. Brent, N. (2018). Can RNs/CMAs without prescriptive authority process refills? Retrieved from https://www.nurse.com/blog/2018/01/08/can-rns-or-certified-medical-assistants-without-prescriptive-authority-process-refills/.

You brought forth great information and ideas regarding this hot topic we are discussing. I agree, Stephanie not only put the patient at risk, but the NP, MD and practice as a whole with her actions. I think most of us agree that she probably thought she was helping both the patient and the NP, however quite the opposite took place. She is very lucky that the patient did not have an adverse reaction to he medication, and for all we know this “persistent” patient may have told Stephanie that this particular antibiotic worked well for her in the past. None the less, Stephanie should not have taken things into her own hands, and should always consult the licensed prescriber that she is phoning medications in under first, under any and all circumstances, no matter how trivial they may seem to her. As I mentioned in a previous post, I myself was a medical assistant for many years prior to becoming a nurse. I had a great relationship with the physicians I worked with, and they trusted me with many things, including phoning in medications for them. We had a great system down, I would help sort through the messages, placing the most important ones on top (such as ill patients asking for medication), and the MD would write what he wanted done, such as patient needs to be seen, or the name of the medications he wished to be phoned in. The MD would always sign his name/initials on the message as well, as a means of authorization. I would then phone the patients that he wanted to be seen so that they can come in for a visit, then I would phone in any authorized prescriptions. We typically performed these tasks between patients in effort to keep both the in person patients waiting to be seen, and the high influx of phone calls, running as smooth as possible. We were always busy, but we had a good system in place, and trust me- we had many “persistent” patients who wanted to have their way or got mad at us if they didn’t get their way as far as medications being phoned in. No matter how busy or behind we were, I never took matters into my own hands without first speaking with the MD. So, if Stephanie attempts to say she was trying to not bother the NP or was trying to save time, this is still no excuse for going outside of her scope of practice. In addition, this cough that the patient has could be viral as many are, or simply not an infection at all. What if it is a side effect from one of her existing medications, or due to a heart issue? These are the considerations that would be taking place with a licensed practitioner, which is ultimately for them to decide what is in the best interest of the patient, the prescriber and the practice.

NR 510 Week 4 Organizational Change and Ethical-Legal Influences in Advanced Practice Nursing Case Study Part Two Discussion