The ultimate goal of every advanced practice nurse (hereinafter, APN) is to provide proper, efficient treatment and care process to the patient and ensure maximal safety of the prescribed medication. Nonetheless, there are diverse cases of wrong prescription by mistake that can result in dysfunction, side effects, complications, and even death of the patient. The given issue provokes a dilemma of further actions the nurse should do as a disclosure. This is a serious malpractice in the course of APN professional performance that involves not only medical but also ethical and legal implications. The present paper focuses on the case of wrong prescription of medication and analyzes potential alternatives of an APN reaction, terms of disclosure, and influence of such a malpractice on the APN competence level and clinic’s reputation.
There are various types of wrong prescriptions of medication, for instance, “missed dose, wrong dosage forms, wrong time interval, wrong route” (Jeetu & Girish, 2010). A particular percentage of mortality, morbidity, and expenses attribute to the malfunction related to wrongly prescribed medicine. One particular case of wrong prescription is connected with difficulties many patients face while reading and understanding the prescription (Jeetu & Girish, 2010). As a result, the errors lead to negative influence of the medication and even lethal ramifications.
First, it is relevant to consider a proper scheme for medication prescription. Cohen (2007) delineates the core obligatory elements of the course of prescription in accordance with the standards and requirements of the federal level, namely: “name and address of dispenser (pharmacy), serial number of prescription, date of prescription or date of filling, name of prescriber, name of patient… drug name, drug strength (if more than one strength was available), quantity dispensed, expiration date, and manufacturer or distributer” (p. 23-24). Furthermore, proper instructions are also important in the given context. The APN is to adhere to the aforementioned rules.
In case a mistake in prescription has been made, there are such alternatives as disclosure and nondisclosure. An unintentional mistake remains a mistake. The APN should realize it and be ready to take responsibility for the actions. Nonetheless, the consequences of disclosure as well as of nondisclosure will be faced not only by the APN but also by the clinic. Admittedly, such a malpractice will decrease the level of credibility and trustworthiness to the clinic, but nondisclosure may lead to even worse ramifications.
Important ethical issues of disclosure include the aspects of trust and professional competence. Bonney (2014) delineates such moral and ethical principles that relate to the issue in question as “autonomy and right to self-determination, the beneficence ethical principle, the right to know principle, the priority of justice and veracity” (p. 83-85). These principles are the underlying priorities the nursing performance should rely on. The principle of beneficence is especially relevant and important in the given context. To be more precise, it advocates for constructive promotion of “benefits to patients by maximizing treatment outcomes while minimizing risks” (Bonney, 2014, p. 84). Hence, the dubious implications of the minimized risks in the currently discussed situation leads to the optimal choice of disclosure in order to ensure the patient’s safety and proper condition of his or her health. Furthermore, the major task of the doctor is to cure as well as to provide the patient with maximally detailed and fair data concerning their health condition, potential threats to it and possible enhancements under particular conditions. This is a domain of the principle according to which every customer has a right to know accurate and truthful information about their health condition and treatment course, and at the same time to know in case there have been mistakes, complications, and new developments. Hence, postponing or hiding information from the customer violates the given principle severely.
The error in prescription violates the underlying principle of patient safety. There is a core principle in the field of medical practice, namely, primum non nocere (first, do no harm). Even an unintentional error in prescription can cause harm. Simultaneously, it is a sign of inadequate competence or dedication of the APN. Nonetheless, the choice of nondisclosure may lead to serious negative effects on the patient, and the safety of the patient and his health will be exposed to bigger danger in comparison with timely and constructive disclosure. Cohen (2007) posits out that disclosure is simpler in case the patient is a regular one and trusts the APN. Along with such, disclosure may even improve the level of trust since the ANP apparently pursues the ultimate purpose of the healthcare process, namely, safety of the patient’s health.
One of the issues that often postpones or eliminates the decision of disclosure is the fear of possible litigation. Cohen (2007) underlines that “the perceived risk of litigation may be exaggerated” (p. 553). It is especially true in cases when the disclosure has been made timely and properly and the patient has had no side effects or complications from the wrongly prescribed medication. The role of a nurse in prescribing practice is crucial since the APN directs the course of treatment and predetermines its potential efficiency to certain extent (Woo & Robinson, 2015). Therefore, any type of malpractice or an error should be adjusted as soon as it has been detected.
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There are diverse opportunities to prevent prescription errors made by APNs. First, it is obligatory to adhere to the standard prescription form that has been mentioned above. Second, it is crucial to “consider the patient’s age, weight, renal and hepatic function, concurrent disease states, laboratory test results, current medications… allergies, and medical, surgical and family history, including pregnancy or lactation” (Cohen, 2007, p.176). It is required to rely on the given results in order to prescribe relevant medicine and a proper dosage. Such a consistent and holistic approach is expected to prevent wrong prescriptions. Furthermore, it is also recommended to warn the patient about possible interaction of the medicine with other pharmaceutical items, products, and specific types of activity. It will prevent side effects and complications. It is also recommended to emphasize proper spelling and pronunciation of the medication, especially in case the patient will use it for the first time since a confusion of similar names of medicine often becomes a reason for further problems with use of prescriptions. In addition, Cohen (2007) opines that the APNs should provide the ultimate purpose of the treatment course in general and each medical item in particular in order to prevent a possible confusion at a pharmaceutical store. Velo and Minuz (2009) highlight that constructive cooperation between doctors and nursing personnel is also a considerable preventive measure in the given context as far as an irrelevant diagnosis or a decision related to the treatment course may often provoke inappropriate prescriptions. The scholars delineate three optimal strategic interventions targeted to prevent possible errors in prescriptions: “reduction of complexity in the act of prescribing by the introduction of automation; improved prescribers' knowledge by education and the use of on-line aids; feedback control systems and monitoring of the effects of interventions” (Velo & Minuz, 2009).
The option chosen for solving the currently discussed conflict is disclosure. It is crucial to appreciate the credit and trust of the patients as well as to provide maximal care about their health condition. Wrong medication is a vivid hazard to the overall health condition, but it is also a threat to the patient’s life. Therefore, the patient should be contacted immediately. It is better to contact the patient personally and to explain the situation in detail. The error should be improved by means of proper prescription. The reasons for the error should be addressed. Apology for such a mistake is an obligatory element of the disclosure process. The risk that such a revelation may impact the reputation of the clinic and the APN is considerable, but it will depend on a particular patient and the severity of the error. Furthermore, the implications of the APN malpractice also depend on specific legal regulations and laws that encompass the course of the professional activity of the APNs. The state of residence is California. According to the regulations imposed by California Board of Registered Nursing, the cases of fines and even citations are applicable in case the nursing personnel “to have standardized procedures when performing overlapping medical functions. NPs are encouraged to comply with all sections of the NPA to avoid discipline” (Bailey, 2011, p. 6). The given case of prescribing malpractice may result in a fine in case the patient will decide to apply to the legal system. Nonetheless, disclosure will position both the APN and the clinic as a constantly enhancing the course of practice, acknowledging the mistakes and learning from them, transparent and fair medical institution.
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Thus, the case of malpractice is a serious professional error. The option of disclosure has been chosen as optimal since it guarantees maximal concern and contribution to the health condition of the patient and adheres to the underlying principles of nursing performance. In addition, it may lead to a fine and influence the reputation of both the clinic and APN negatively.