An RN who works in a physician’s office raised a concern about whether she had the authority to send an e-prescription to a pharmacy when the physician gave a verbal order for non-opioid prescriptions.
E-prescriptions have been the subject of several of my recent blogs, including “Could a nurse be liable for an incorrect prescription being given to a patient?” and “Can RNs/CMAs without prescriptive authority process refills?”
E-prescriptions are nothing new in today’s healthcare arena. But when not handled properly, they can potentially pose legal risks to an RN in an office setting.
What legal risk could befall you?
The biggest legal problem in this situation is the verbal order from the physician. As you know, in the hospital setting, verbal orders are regulated by the institution’s policies.
For example, a verbal order would most likely be prohibited for a Do Not Resuscitate Order. Rather, an institution’s policy would require a written order by a physician and a written DNR form completed and made a part of the patient’s medical record, either as narrative originals or as part of an Electronic Medical Record.
Such a policy ensures the order was, in fact, directed by the physician, was documented properly and the required form filled out.
In an office setting, however, none of these protections are usually afforded you. As a result, if you misunderstood the verbal order in some way (e.g., medication ordered, dosage ordered) and the patient is injured as a result of your misunderstanding, legal liability might ensue in the form of a professional negligence suit.
Defending yourself against a misunderstanding allegation is difficult in this situation. The physician may take the position that he or she did not order what you e-prescribed to the pharmacy. Or, if he or she did, your e-prescription was in error. Clicking on the wrong medication to be filled on the patient’s medication list or typing in the wrong dosage would be the basis of your error, as examples.
You can help reduce your liability concerning verbal orders in several ways. One is to ask that a policy be developed in the office for nurses concerning verbal orders. For example, the policy could indicate that no verbal orders can be given for e-prescriptions by nursing staff unless there also is a written order in the patient’s medical record.
In addition to a policy you must follow, the development of standing orders by the physician for those medications he or she prescribes can reduce your potential liability. The physician can write the order in the patient’s medical record pursuant to the adopted policy, and then you consult with the standing order(s) for that medication and for that patient.
If a policy or standing orders are not developed, another way to reduce your liability is to document clearly in the patient’s record the verbal order as you would any verbal order in a hospital setting. That is, you would document what the verbal order was, who gave it, the time and date, and when you e-mailed the prescription to the pharmacy.
Another legal risk
Your state nurse practice act, its regulations and any practice guidelines published by a board of nursing govern your nursing practice at all times and in all healthcare settings.
Therefore, if your act or board practice guidelines control verbal orders and/or e-prescriptions, and your e-prescription violates one or more of its provisions or a guideline, you may face a board of nursing professional disciplinary proceeding.
You also would face a possible board of nursing professional disciplinary process if you e-prescribed a verbal order that doesn’t follow an established office policy concerning e-prescriptions by nursing staff.
Remember that anyone can file a complaint with the board of nursing if that person thinks there is a valid reason to report you.
In relation to e-prescriptions, a fellow nursing staff member at the office might contact the board if you are not following office procedure.
Or a family member may raise a provision in the act or its regulations concerning your responsibilities in e-prescribing. That person might allege that how you send e-prescriptions is outside your scope of practice.
Remember, too, that a board of nursing professional disciplinary process does not have to be based on a patient injury or death. Rather, the focus is on a violation of one or more of the nursing act provisions or a practice guideline.
This brief blog cannot cover all of the issues you face, legal or otherwise, with e-prescribing.
The 2015 research study, “Exploring Nurse Engagement With Electronic Health Records and E-Prescribing,” focused on nurses’ roles in an ambulatory setting in a Midwestern rural hub. It further identifies how your role is impacted and how your participation influences e-prescribing.
Take these courses to learn more about e-prescription:
Legal Landscape of Electronic Prior Authorization (ePA) and Its Effect on Patients and Prescribers
(1 contact hr)
The goal of this presentation is to discuss ePA mandates, points of access to ePA, the role of plans, and the effect of ePA solutions on patient care and outcomes. Upon completion of the webinar, participants will be able to explain the electronic prescription drug prior authorization process and recall named standards, identify states that have legislation surrounding electronic submission of PA requests, describe requirements of various PA legislation, identify access points to ePA solutions and the effect of ePA legislation on prior authorization process, discuss the current state of ePA availability and adoption re: different factors, and explain prior authorization workflow to patients/caregivers.
Toxic Alert: Many Common Drugs Can Damage Kidney and Liver
(1 contact hr)
Although often assumed safe, prescription and OTC medications can cause serious adverse reactions, especially in certain high-risk populations. Acetaminophen (Tylenol) and aspirin are associated with an increased risk of chronic renal failure. These drugs, as well as ibuprofen, are ingredients in many OTC and prescription medications. In addition, with the increase in popularity of complementary medicine (in 2007, about 40% of U.S. adults used complementary or alternative medicine), herbal therapy toxicities occur at an accelerated rate. Specifically, OTC drugs, prescription drugs and even herbal products can target the kidney and liver. The causes of these reactions and toxicities are complex, and certain patient populations are more susceptible. Because these reactions are preventable when users are educated about the risks and screened for risk factors before therapy, healthcare providers across disciplines must be able to identify the drugs and their potential toxicities to ensure patient safety.
Responsible Opioid Prescribing
(2.5 contact hrs)
The increased emphasis on management of pain to improve quality of life and functionality of people with chronic pain has contributed to a significant increase in the number of opioid prescriptions being written. With increased availability of prescription pain medicine, there has been an increased risk of misuse and abuse. This educational activity will address issues related to the regulation, medical management, misuse, abuse and diversion of controlled substances.