As a nurse practitioner, you must know legal obligations when prescribing medications. You have the authority, based on your state nurse practice act, to prescribe medications for the patients for whom you provide care. For example, states that allow prescriptive authority in some form include Florida, Utah and Pennsylvania.
Regardless of the scope of your prescriptive authority, one overall standard of practice and standard of care is to ensure that any medication you prescribe is compatible with other medications your patient is taking. A 2014 professional negligence case (Huelskamp v. Patients First Health Care, E.D. 100686, Missouri Court of Appeals, Eastern District) emphasizes these standards.
Patient S.H. saw a psychiatric nurse practitioner for her depression and was prescribed the antidepressant Lamictal. According to the NP, the patient was informed the medication could cause a rash and if that occurred, the patient was to stop taking the medication and call the nurse practitioner.
Patient starts another medication
The patient then began treatment for high blood pressure with another NP at the same clinic. The family NP reviewed the patient’s medications and saw that she was on Lamictal.
On a subsequent visit for body aches, the family nurse practitioner prescribed the antibiotic Amoxicillin without researching the antibiotic and without checking into Lamictal for potential side effects and whether a black box was present that would highlight any safety concerns.
Shortly after this visit, the patient contacted the family NP and complained of a rash, and the family NP agreed to treat her for it. Again, the NP did not delve into Lamictal’s side effects, did not instruct the patient to discontinue the medication, and did not tell the patient to contact the nurse practitioner who prescribed it to determine if she should continue taking the medication. Rather, the family NP told the patient to stop taking the antibiotic and to take Benadryl instead.
A second visit took place several days later. The rash had continued and the family NP prescribed a Medrol Dosepak and told the patient to contact her in two days. No investigation into Lamictal was done and the patient continued taking that medication.
The rash became worse so the family NP suggested the patient see a dermatologist, who instructed the patient to stop the Lamictal due to one of its side effects being a rash. The patient stopped the medication.
Shortly after the visit with the dermatologist, the patient was admitted for Stevens-Johnson syndrome which progressed to toxic epidermal necrolysis, involving 98% of her body.
The patient filed a medical malpractice case against Patients First Health Care for the care provided by the family NP, alleging professional negligence, lost wages, sustained pain and suffering, and incurred medical bills.
After several legal motions at the trial court level, the jury entered a verdict for the patient in the amount of $525,000. Patients First filed several additional motions, which were denied and it appealed those denials to the Missouri Appeals Court.
The Appeals Court upheld the verdict entered by the trial court. In doing so, it carefully reviewed the evidence surrounding the plaintiff’s case.
One piece of evidence was quite astonishing. The family NP testified that she believed she was responsible only for knowing the potential side effects of medications she personally prescribed and that any side effects of medications prescribed by others were not a consideration when caring for her patients. Nor did she see it important to contact the other nurse practitioner who prescribed the Lamictal or instruct the patient to do so.
Such conclusions by the family nurse practitioner are staggering. It is fair to say that neither are beliefs that most nurse practitioners would embrace. Even so, it bears emphasizing that your prescriptive authority, however defined by your state board of nursing, must be consistent with standards of practice established by your professional nursing associations, such as the American Association of Nurse Practitioners, and be consistent with the overall standard of care by which your care is measured if sued for professional negligence.
What nurses need to know
Although not an inclusive list of your legal obligations when prescribing medications, this case illustrates that you should:
- Be knowledgeable about any medication you prescribe, including side effects;
- Do a careful assessment about any medications the patient is currently taking, including side effects, black box warnings and dosages;
- Contact any other prescribers who are working with the patient when there is a question about any untoward developments the patient experiences after starting any medication, whether it is one you prescribed or one another provider prescribed;
- Carefully and accurately document your assessments, actions, contacts and instructions to the patient; and
- Remember that you may also face a disciplinary action by your state board of nursing for a violation of your obligations under your state nurse practice act.
A full list of states offering some form of prescription authority is available at aanp.org.