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I work in a busy cardiology practice. Recently the physicians told the nurses that we can change certain drug orders without review by a physician or the physician assistant. For example, if a physician orders ramipril (Altace) but the patient's insurance won't cover it, we can change the drug to lisinopril (Zestril) and adjust the dosage according to prescribing information obtained from the Internet.


None of us are advanced practice nurses. We believe that following this policy amounts to prescribing drugs without a license and exceeds the scope of nursing practice. But we're having a hard time making this argument because my state has no nurse practice act, and the board of nursing won't provide legal advice. Can you help?-P.V., MICH.


Our legal consultant confirms that Michigan's nurse practice act has been rolled into the Public Health Code. Various sections of the code address a nurse's scope of practice during drug administration. For example, several sections specify circumstances in which a supervising physician can delegate to an RN the "ordering, receipt, and dispensing of complimentary starter dose drugs." However, the situation you describe doesn't seem to fit into these "complimentary starter dose" provisions, so you're right to be alarmed. An RN who changes a prescription order would be considered to be practicing medicine without a license unless the physicians sign off on the prescription form.

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Our advice? If you want to continue working in this office, tell the physician that their policy is outside the scope of nursing practice. If necessary, seek advice from an attorney with expertise in your state's nursing law to bolster your opposition to this flawed policy. If the physicians won't budge, seek employment elsewhere to protect your license.