1. Brooke, Penny Simpson JD, MS, APRN

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Dangerous delegation

I'm an RN working in an outpatient primary care practice. In the last year, the practice has been cutting costs by replacing RNs who leave with certified medical assistants (CMAs) instead of hiring new RNs. As a result, our workload has increased because we can't legally delegate certain tasks to the CMAs. But we see the physicians delegating jobs to CMAs that really should be done by an RN, such as giving patients oral medications. Is this legal?-G.S., MD


The trend toward replacing RNs with CMAs is worrisome because the level of care patients receive is affected by the provider's level of expertise.

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Most medical practice acts allow physicians to delegate just about anything to anyone. Although nurses can't accept responsibilities that are beyond the scope of their RN license, CMAs can accept most tasks delegated to them by the physician. Outpatient settings aren't regulated in the same way as hospitals, and physicians typically set their own policies and procedures.


To protect yourself, find out whether the office has clear, written policies that clearly exempt RNs from responsibility for the actions of the CMAs in the office. The physician must be the responsible party when it comes to delegating tasks to CMAs; otherwise the RNs will also be implicated if a CMA makes a mistake that harms the patient and results in a lawsuit. Don't delegate nursing tasks to the CMAs yourself, or you'll find yourself in trouble with your state's board of nursing.


If your office has no policy in place, you're at risk legally. If the risk becomes too great in this outpatient setting, you may wish to seek other employment.



Good nursing care or insubordination?

The other day, I refused to administer a medication because the dose was significantly higher than the commonly prescribed dose; also, the patient's condition wasn't an approved indication for this medication. The physician has reported me to my supervisor for insubordination. Apparently this higher dose and new use are a cutting-edge application of this medication. Was I wrong to refuse to administer what seemed like an overdose of an inappropriate drug?-N.W., CALIF.


Nurses are expected to understand the dosage and common uses of medications they administer. You were using this information when you refused to administer a drug that you believed might harm the patient. This is good nursing practice. But even if the drug or dosage is potentially unsafe, you can't simply disregard the prescription.


Prescribing a medication for an unapproved use is known as off-label prescription. Legally, a physician can prescribe an FDA-approved medication for any purpose and at any dosage, regardless of recommendations in the package insert. However, he or she should be able to provide a rationale for a prescription that deviates from normal use. Healthcare facilities should have a policy and procedure for off-label prescriptions that includes a process for peer review and escalation up the chain of command to resolve any concerns about the safety or appropriateness of the prescription.


If you're not convinced that a prescription is safe, you can refuse to give the medication yourself. But again, you must follow policy and procedure to notify appropriate personnel, such as the prescriber, your manager, pharmacy, and hospital administration. Depending on circumstances, your manager may administer the medication or the prescriber may be required to administer it. If the medication is withheld, document in the patient's medical record that the drug was not given and why. Submit an event report according to hospital policy.


Hopefully your supervisor will agree that you weren't being insubordinate, but rather were taking an informed action intended to protect the patient. But keep in mind that withholding a prescribed medication could also be unsafe. If a similar situation arises in the future, take care to follow all protocols to ensure the best outcome.