NUR 6521 MA is an 85-year-old female living in a long-term care facility. She has significant cognitive decline, and her physician has even said that death is near with her other health issues including renal failure and CHF. She has been on blood thinners for years due to a valve replacement 20 years ago. She cries in agony with each fingerpick and can barely tolerate the lab draws if needed to check her INR. Is continual monitoring of the INR needed given her terminal status?

NUR 6521 MA is an 85-year-old female living in a long-term care facility. She has significant cognitive decline, and her physician has even said that death is near with her other health issues including renal failure and CHF. She has been on blood thinners for years due to a valve replacement 20 years ago. She cries in agony with each fingerpick and can barely tolerate the lab draws if needed to check her INR. Is continual monitoring of the INR needed given her terminal status?

NUR 6521 MA is an 85-year-old female living in a long-term care facility. She has significant cognitive decline, and her physician has even said that death is near with her other health issues including renal failure and CHF. She has been on blood thinners for years due to a valve replacement 20 years ago. She cries in agony with each fingerpick and can barely tolerate the lab draws if needed to check her INR. Is continual monitoring of the INR needed given her terminal status?

A medication error (ME) is a preventable event caused by inappropriate medication use. The health risks linked with MEs threaten patients’ lives and contribute to adverse effects. In the given case study, MA, an 85-year-old female, has marked cognitive decline, and the physician mentioned she might not live long due to her other health issues like renal failure and CHF. She is on blood thinners and can hardly tolerate the lab draws to check her INR. The purpose of this paper is to analyze the ethical and legal implications of the scenario for different stakeholders and describe disclosure and nondisclosure strategies and the process of writing prescriptions.

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Ethical and Legal Implications

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NUR 6521 MA is an 85-year-old female living in a long-term care facility. She has significant cognitive decline, and her physician has even said that death is near with her other health issues including renal failure and CHF. She has been on blood thinners for years due to a valve replacement 20 years ago. She cries in agony with each fingerpick and can barely tolerate the lab draws if needed to check her INR. Is continual monitoring of the INR needed given her terminal status?
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Ethical implications evident in the case concern the principles of beneficence and nonmaleficence. The clinician has an ethical duty to implement interventions that will improve the patient’s quality of life (QoL) without compromising the patient’s safety. Lab draws elicit pain in the patient, and she barely tolerates them. Thus, if the clinician continues to order more INR tests, ethical implications of failing to uphold nonmaleficence may arise (Varkey, 2021).   The patient has a right to refuse treatment interventions. Legal implications may arise if her autonomy is not respected and the clinician insists on performing lab tests.

Strategies to Address Disclosure and Nondisclosure

Various organizations endorse the disclosure of MEs, including the Joint Commission, which requires disclosure of unexpected care outcomes. Disclosure safe practice entails standards for healthcare providers concerning the fundamental components of disclosure. Healthcare organizations are called upon to create a conducive environment for disclosure by integrating risk management and patient safety activities and training and supporting health providers (Mansour et al., 2020). Alabama law (Code R. 420-5-4-.05) requires that any medication error, overdose, or over-sedation incident be immediately reported to the attending physician, facility medical director, or backup physician (CoCounsel, n.d.). However, there is no law mandating the disclosure of MEs to patients.

Strategies to Use as an APRN to Guide Decision Making

The APRN’s strategies to address the disclosure dilemma will be to apply the organization’s policy and the state laws on disclosing medication errors. Healthcare organizations have policies that guide providers on the actions to take when there is a ME and the circumstances under which the error should be disclosed or not disclosed to the patient. Therefore, as an APN, I would review our organization’s policy on disclosure and take the steps recommended (Mansour et al., 2020).

In addition, I would review the state’s law on disclosing ME to patients, which is crucial to avoid legal consequences. If the state law mandates disclosure of ME to patients, I will ensure to disclose it to the patient and explain how it occurred. When disclosing the ME, I would start by informing the patient that an error occurred and describe the course of the incident using simple language (Mansour et al., 2020). I would also explain the nature of the ME, its potential effects, and corrective interventions that will be taken to mitigate the error. Furthermore, I would convey personal regret and apologize to the patient and address the questions the patient will ask.

Process of Writing Prescriptions and Strategies to Minimize Medication Errors

Appropriate writing of prescriptions is a fundamental part of patient care by which the APRN can influence a patient’s health and well-being. When writing a drug prescription, the APRN must ensure it is legibly printed or typed. The APRN should write the following: The patient’s name, sex, age, and diagnosis; The name of the prescribing practitioner;  Name and strength of the medication;  Quantity of the medication in textual and numeric formats;  Directions for use; Drug refills (Imran et al., 2020). The APRN should write the date, preferably with the month written in text (May 30, 2023, not 5/30/23). The prescribing clinician should sign the prescription on the day when issued.

MEs can be reduced by adopting health technology like E-prescribing software and clinical decision support system (CDSS). The E-prescribing software checks drug information databases for appropriate prescribing guidelines, the patient’s medication profile for drug interactions, and the patient’s medical record for disease contraindications (Vilela & Jericó, 2019). Besides, the CDSS supports clinicians with dose guidance and checking for drug allergy and drug-drug interactions, which improve medical decisions and prevent MEs. Furthermore, nurses can prevent MEs by adhering to the 5Rs of medication administration: Right drug, Right dose, Right route, Right time, and Right patient.

Conclusion

Ethical and legal consequences may arise if providers implement interventions that continuously cause patient discomfort or pain or act against the patient’s will. Organizations should create conducive environments to encourage the disclosure of errors. Medication errors can be minimized by adopting health technology like E-prescribing software and CDSS. 

References

CoCounsel. (n.d.). ALA. Admin. Code R. 420-5-4-.05. Casetext – CoCounsel. https://casetext.com/regulation/alabama-administrative-code/title-420-alabama-state-board-of-health/chapter-420-5-4-assisted-living-facilities/section-420-5-4-05-records-and-reports

Imran, M., Doshi, C., & Kharadi, D. (2020). Time to teach basic and regulatory aspects of the art of prescription writing for better doctor-patient safety and keeping communication accessible and straight. Daru: Journal of Faculty of Pharmacy, Tehran University of Medical Sciences28(1), 25–32. https://doi.org/10.1007/s40199-018-00236-1

Mansour, R., Ammar, K., Al-Tabba, A., Arawi, T., Mansour, A., & Al-Hussaini, M. (2020). Disclosure of medical errors: physicians’ knowledge, attitudes and practices (KAP) in an oncology center. BMC Medical Ethics21, 1-8. https://doi.org/10.1186/s12910-020-00513-2

Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice: International journal of the Kuwait University, Health Science Centre30(1), 17–28. https://doi.org/10.1159/000509119

Vilela, R., & Jericó, M. C. (2019). Implementing technologies to prevent medication errors at a high-complexity hospital: analysis of cost and results. Einstein (Sao Paulo, Brazil)17(4), eGS4621. https://doi.org/10.31744/einstein_journal/2019GS4621

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Case Study:

MA is an 85-year-old female living in a long-term care facility. She has significant cognitive decline, and her physician has even said that death is near with her other health issues including renal failure and CHF. She has been on blood thinners for years due to a valve replacement 20 years ago. She cries in agony with each fingerpick and can barely tolerate the lab draws if needed to check her INR. Is continual monitoring of the INR needed given her terminal status?

Write a 2- to 3-page paper that addresses the following:

Explain the ethical and legal implications of the scenario you selected on all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family.

Describe strategies to address disclosure and nondisclosure as identified in the scenario you selected. Be sure to reference laws specific to your state.

Explain two strategies that you, as an advanced practice nurse, would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation.

Explain the process of writing prescriptions, including strategies to minimize medication errors.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

References: 5

RESOURCES:
American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767
American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults by American Geriatrics Society, in Journal of the American Geriatrics Society, Vol. 67/Issue 4. Copyright 2019 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing via the Copyright Clearance Center.

This article is an update to the Beers Criteria, which includes lists of potentially inappropriate medications to be avoided in older adults as well as newly added criteria that lists select drugs that should be avoided or have their dose adjusted based on the individual’s kidney function and select drug-drug interactions documented to be associated with harms in older adults.

Drug Enforcement Administration. (2021). CFR – Code of Federal Regulations Title 21. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=1300
This website outlines the code of federal regulations for prescription drugs.

Drug Enforcement Administration. (n.d.). Mid-level practitioners authorization by state. Retrieved May 13, 2019 from http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html
This website outlines the schedules for controlled substances, including prescriptive authority for each schedule.

Institute for Safe Medication Practices. (2017). List of error-prone abbreviations, symbols, and dose designations. Retrieved from https://www.ismp.org/recommendations/error-prone-abbreviations-list
This website provides a list of prescription-writing abbreviations that might lead to misinterpretation, as well as suggestions for preventing resulting errors.

Sabatino, J. A., Pruchnicki, M. C., Sevin, A. M., Barker, E., Green, C. G., & Porter, K. (2017). Improving prescribing practices: A pharmacist?led educational intervention for nurse practitioner students. Journal of the American Association of Nurse Practitioners, 29(5), 248–254. doi:10.1002/2327-6924.12446

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