Administer Meds Without a Doctor's Order? Proceed With Caution
Registered nurses generally should administer medications only with a physician’s order. Only certain advanced practice nurses have prescriptive authority, and their qualifications, as well as the type of drug and the amount they are allowed to prescribe, vary from state to state.1 Nonetheless, in certain circumstances it may seem appropriate to administer medication without a direct order. Here’s what you need to know about when you can do so and how to proceed.
When an emergency situation calls for action
In an emergency, you may think you do not have enough time to obtain a physician’s order before providing life-saving medication to a hospitalized patient. This is not sufficient reason to provide the medication, however, because in doing so you could be stepping outside the scope of your clinical privileges. Depending on your facility’s procedures, you may well be taking a risk that jeopardizes your patient, your facility and your ability to practice nursing. If at all possible, get an order first.
If you provide emergency care to a patient outside of your place of employment, however, a different standard applies. According to Joanne Sheehan, JD, RN, BSN, an attorney with Friedman, Newman, Levy, Sheehan and Carolan in Fairfield, CT, every state has Good Samaritan laws that protect healthcare providers from liability if they provide emergency care in good faith. Such care would include giving a man who had a heart attack nitroglycerin if he had it with him, for example. These laws have certain “gray” areas and vary slightly from state to state. So it is up to you to familiarize yourself with and understand those laws in your state.
Standing or PRN orders help alleviate risk
Many facilities have implemented standing orders or practice protocols that nurses can use to provide medications to patients without a direct physician’s order. Standing orders spell out what you can do under a specific set of circumstances with a particular patient population, according to Gayle H. Sullivan, JD, RN, president of Quality Assurance Associates, Inc., a medical liability consulting firm in Fairfield, CT. As long as you adhere to the criteria set forth in the standing order for providing a certain therapy, follow the steps of the order and document your actions, you should be protected from liability.
So, if your facility has a standing order allowing you to administer epinephrine to a patient having an anaphylactic reaction, you can do so without fear of reprisal. Likewise, a PRN order for a nitroglycerin patch in the chart of a patient with cardiac problems means a nurse can provide the medication without overstepping her bounds. Even if these types of orders exist in your facility, make sure the actions fall within your scope of practice and the laws in your state. If state law prohibits a nurse from administering immunizations to patients using a standing order, for example, you cannot do so without putting your license at risk. If your facility implements a standing order or expects the nursing staff to adhere to a PRN order that conflicts with state or federal law or your Nurse Practice Act, bring it to the attention of your risk manager or administrator at once. Facility protocols do not supersede the law.
When a friend asks for an OTC drug
Although nurses are not licensed to order medications, it’s unlikely that you will be sued if you give a friend acetaminophen for a headache, according to Sullivan. Once you give professional advice, however, you create a duty to treat. Similarly, you establish a duty to treat if you accept payment for the care you provide, said Sheehan. Once you’ve created that nurse-patient relationship, you have an obligation to do a nursing assessment and obtain your patient’s history.
Caring for patients, controlling your risk
Giving a patient medication—whether prescribed or over-the-counter—without a physician’s or nurse practitioner’s knowledge has many risks. Most important, the medication could be contraindicated, even if it seems innocuous. If the patient is harmed, you and your facility could be sued for malpractice. In addition, you could be charged with taking action outside the scope of nursing practice, which could put both your job and your license in jeopardy. This action could be construed as practicing medicine and possibly lead to criminal charges.
Ultimately, the best way to minimize your risk when giving medication to a patient is to make sure you have an order from a primary care provider (PCP) in the first place. “A simple call to the patient’s PCP is all it takes,” said Sheehan. Once you have the order, make sure you administer the medication safely and appropriately. Use the five “rights” of drug administration: Make sure you give the right drug to the right patient, in the right dose using the right route at the right time.2 Finally, thoroughly and accurately document the PCP’s order, your patient assessment and your actions in the medical record. Administering medications needn’t be risky, if you stay within the scope of your practice.
1.American Nurses Association. "American Nurses Association 2000 Prescriptive Authority Chart." Feb. 1, 2000. http://www.nursingworld.org/gova/charts/dea.htm (3 Oct. 2004).
2.Institute for Safe Medication Practices. "The 'five rights'" April 7, 1999. www.ismp.org/msaarticles/fiverights.html (3 Oct. 2004).