Speaking Up for Safety: The Nurse’s Role in Carrying Out Medication Orders – Post Test

OUTCOME: The learner will demonstrate sufficient knowledge related to the legal and ethical principles of medication safety and nursing practice by achieving a score of 80% or higher on post-test.

1 Category A contact hour will be awarded with successful completion.

The Ohio Nurses Association is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (OBN-001-91).

Expires 5/31/2021

1. Please read the study.
2. Complete the post test. To be awarded contact hours, you must achieve a score of 80% or higher.

If you have any questions, please feel free to contact Sandy Swearingen (sswearingen@ohnurses.org).

This independent study was developed by: Jessica Dzubak, MSN, RN. There is no conflict of interest among anyone with the ability to control content for this activity.

The profession of nursing has come a long way from white dresses and caps. Nurses are no longer viewed as servants to doctors, but as our own profession with a unique set of skills and expertise. With this increased respect comes an increased responsibility. While nurses are taught to carry out orders placed by physicians or other advanced practice personnel, there are critical steps that must be taken before any order is completed.
Unfortunately, the media has shown us that medical errors continue to happen all across the country. It isn’t just small, rural hospitals with limited resources. Mistakes can happen anywhere in any healthcare facility. The good news is, with diligence and good clinical judgement, many medical errors can be prevented or stopped before it is too late.

The American Nurses Association (ANA) describes “culture of safety” as “describes the core values and behaviors that come about when there is a collective and continuous commitment by organizational leadership, managers and health care workers to emphasize safety over competing goals” (American Nurses Association, 2016, para. 3). The “culture of safety” concept as described by the Patient Safety Network, a subset of the Agency for Healthcare Research and Quality, (2019) recommends these key essential qualities:

– acknowledgment of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations (Patient Safety Network, 2019)
– a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
– encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
– organizational commitment of resources to address safety concerns

While it is important to maintain a “blame-free” environment and an organizational culture of safety, nurses must understand their responsibilities and ethical commitment to safe practice. Nurses must also be aware of the potential legal repercussions that may ensue if an error should occur, such as lawsuits or licensure revocation.

A 2018 article on safety culture in American Nurse Today identified four takeaways
• Direct care nurses are error identifiers.
• Organizations are accountable for their systems.
• Nurse leaders are responsible for developing an environment where it’s safe to speak up.
• Collaboration is essential to patient safety (Paradiso, 2018).

We must not only be aware of our own actions and processes, but be confident in our abilities to speak up. Nurses can lead by example and empower their healthcare colleagues to create a culture of safety and uphold the Provisions detailed in the ANA Code of Ethics.

In the Media
In 2019, a nurse was charged with reckless homicide for a fatal medication error. Prosecutors allege she made at least 10 mistakes during medication administration, including overriding safety measures. This case gained a lot of media exposure and begged the question of whether or not criminal charges were appropriate for this nurse. While everyone may have a different personal opinion on the case, the takeaway is that safety measures are put in place for a reason and should always be followed. This case highlights the impact one medication error can have on both the patient’s and the nurse’s life.

What everyone should be asking after hearing about these situations is ‘how can we do better?’ What could be done differently next time? The goal is not to place blame, but to place emphasis on the importance of adhering to safety measures and speaking up for safety.

What does the law say?

OAC 4723:
(4) When the nursing care is to be provided according to division (B)(5) of section 4723.01 of the Revised Code, the nurse has a specific current order from an individual who is authorized to practice in this state and is acting within the course of the individual’s professional practice; and
(5) The nursing care does not involve a function or procedure that is prohibited by any other law or rule.
(E) A registered nurse shall, in a timely manner:
(1) Implement any order for a patient unless the registered nurse believes or should have reason to believe the order is [emphasis added]:
(a) Inaccurate;
(b) Not properly authorized;
(c) Not current or valid;
(d) Harmful, or potentially harmful to a patient; or
(e) Contraindicated by other documented information; and
(2) Clarify [emphasis added] any order for a patient when the registered nurse believes or should have reason to believe the order is:
(a) Inaccurate;
(b) Not properly authorized;
(c) Not current or valid;
(d) Harmful, or potentially harmful to a patient; or
(e) Contraindicated by other documented information.

Reflection Question #1: Can you think of a time when a situation like this happened in your own practice? Have you ever had to question an order? What did you do? How were your actions received?

Once you determine you need further clarification before carrying out the order, what do you do next?
4723-4-03 OAC states:
(F) When clarifying an order, the registered nurse shall, in a timely manner:
(1) Consult with an appropriate licensed practitioner;
(2) Notify the ordering practitioner [emphasis added] when the registered nurse makes the decision not to follow the order or administer the medication or treatment as prescribed;
(3) Document that the practitioner was notified of the decision not to follow the order or administer the medication or treatment, including the reason for not doing so; and
(4) Take any other action needed to assure the safety of the patient.

Notice how the law explicitly states that the registered nurse has full authority to make the decision not to carry out the order or administer the medication. With a valid reason, this is within the nurse’s scope of practice in the state of Ohio.

Some examples of medication orders that may need clarified:
1. The nurse receives an order for pain medication higher than the standard dose.
2. The physician orders a medication that the nurse knows is contraindicated for this patient.
3. The nurse receives an order for a medication they are unfamiliar with.

Just because the order seems confusing in the beginning does not mean there is a problem. Sometimes there may be a valid reason for the order, but it is the nurse’s responsibility to seek clarification and document the information received. The documentation shows that the nurse did his/her due diligence to practice the five rights of medication administration and can make a big impact should there ever be a review or legal case.

In all cases, the ordering practitioner should be notified that the medication was not given or the order not carried out. If the nurse feels that further action is necessary but does not feel comfortable with the original ordering practitioner, another licensed practitioner should be immediately consulted and all actions documented.

Special Situations:
Say the nurse clarifies an order for pain medication at a higher than usual dose. The nurse knows her patient is already lethargic and confused, and she is concerned about administering the medication. The physician states that is the dosage she wants to order, but the nurse feels very uncomfortable. What should the nurse do?
a. Administer the medication anyway. The physician said it was safe.
b. Give the medication, but at a lower dosage.
c. Do not administer the medication, notify physician and follow appropriate chain of command, and document accordingly.

The best course of action is C: Do not administer the medication and document accordingly. Per 4723, the nurse has a legal obligation to only carry out orders he/she believes is safe and in the best interest of the patient, not just because an order is present.

It is within the nurse’s professional rights to explain why he/she does not feel comfortable administering the medication and documenting as such. The nurse is “legally and ethically bound to question an inappropriate order from a physician” (Reuter & Fitzsimons, 2013).
Say the nurse does give the medication and an adverse event occurs as a result. Is the nurse responsible?

Reflection Question #2: Say the nurse does give the medication and an adverse event occurs as a result. Is the nurse responsible?

When a nurse administers a medication, he/she is acknowledging the responsibility that comes with it. By administering, the nurse is demonstrating that he/she understands the purpose of the medication and have deemed it safe and appropriate.

4723-4-03 states that:
(B) A registered nurse shall maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice.
(C) A registered nurse shall demonstrate competence and accountability in all areas of practice in which the nurse is engaged including:

Maintaining current knowledge and accountabilities for safe nursing practice includes medications and medication safety. If the nurse is unclear about a specific medication or its dosage, further clarification is needed. Simply saying you don’t know is unacceptable. An article on Best Practices for Medication Errors states “Continuing education of the nursing staff can help reduce medication errors. Medications that are new to the facility should receive high teaching priority. Staff should receive updates on both internal and external medication errors, as an error that has occurred at one facility is likely to occur at another” (Anderson, 2015, para. 21).
“The nurse, on the other hand, is not expected to share the doctor’s knowledge of drugs and their reactions, although she is expected to have sufficient grasp of these things to recognise unusual drugs and dosages and thus to query them if she is unsure. She must also have some grasp of side effects to alert her quickly to a patient’s adverse reactions. In addition, the nurse is expected to address herself swiftly to any deficiencies in the above by asking for information or looking it up” (de Raeve, 2002, para. 7).

In the case of the higher dosage pain medication, the nurse knew using his/her clinical judgment that the dosage may result in adverse effects but still went ahead and administered the drug. Therefore, he/she is still responsible.

“In clinical judgment, with the existing condition, after deep thinking and reflective thinking based on observation, the nurse can collect the data purposefully by interview and examination. Based on the interpretation of data, the nurse performs information processing. After analysis, with rethinking and reflection on the subject, the nurse reaches a final conclusion. In this process, the nurse uses skills such as experience, knowledge, evidence, critical thinking, reasoning, and intuition” (Seidi, Alhani, & Ardalan, 2017, para. 4). Technology cannot replace the critical thinking and judgment nurses possess. In a busy world with many automated processes, it can be easy to fall into auto-pilot, but we must be cognizant of our practices in order to avoid this. Nurses remain the most trusted profession year after year because of our reputation to do the right thing and keep our patient’s welfare as our first priority. We do this by following the nursing process and utilizing the skills we have in order to provide the best, and safest, care.

4723-4-07 discusses how the nursing process is applied to nursing law in Ohio.

It states:
(1) Assessment of health status:
The registered nurse shall, in an accurate and timely manner:
(a) Collect data. This includes:
(i) Collection of subjective and objective data from the patient, family, significant others, or other members of the heath care team. The registered nurse may direct or delegate the performance of data collection; and
(ii) Documentation of the collected data.
(2) Analysis and reporting:
The registered nurse shall, in an accurate and timely manner:
(a) Identify, organize, assimilate and interpret data;
(b) Establish, accept, or modify a nursing diagnosis that is to be addressed with applicable nursing interventions; and
(c) Report the patient’s health status and nursing diagnosis as necessary to other members of the health care team;
(3) Planning:

The registered nurse shall, in an accurate and timely manner:
(a) Develop, establish, maintain, or modify the nursing plan of care consistent with current nursing science, including the nursing diagnosis, desired patient outcomes or goals, and nursing interventions; and
(b) Communicate the nursing plan of care and all modifications of the plan to members of the health care team;

All of these responsibilities should be applied in each day of one’s nursing practice regardless of setting. Administering medications requires diligent, careful consideration of all of these steps prior to doing so.

Using 4723-4-07, think through the following case study:

The nurse is caring for a patient on the floor. A new antibiotic is ordered, and when the nurse pulls it from the electronic medication dispensary, a flag appears that there is a contraindication with another medication the patient is taking. The nurse recognizes this interaction and knows it can be very serious. However, the pharmacist verified the medication. The nurse asks the patient about it and the patient confirms he is taking the medication that may interact.

What should the nurse do?
A. The pharmacist verified it and the physician ordered it, so the interaction must not be that bad. OK to administer.
B. Give the medication, but warn the patient there may be an interaction.
C. Do not give the medication and discuss with the ordering physician and/or pharmacist.

The best answer is option C. This situation warrants further investigation prior to the nurse administering the drug. The nurse’s own clinical knowledge tells her that there is a known interaction between the two drugs. The system flags it as well. By hitting ‘acknowledge’ on the system, the nurse is signifying that she is aware of the potential risk of administering the drug.

The nurse took the next step and confirmed the patient is actually taking the medication in question. While there is an active and verified order for the medication, it is still the nurse’s duty to do the safest intervention for the patient. The nurse can have a discussion with the ordering practitioner about her concerns. Regardless of what information is learned, if the nurse does not feel comfortable administering this medication knowing about the interaction, she may decline and should document appropriately.

The nurse manager on the unit praised the nurse in the above example for this “near miss”. There could have been a potential medication error and patient safety could have been jeopardized. The nurse’s diligence protected the patient and this behavior should be emulated. Many organizations have “near miss” reporting systems and policies to encourage the reporting of incidents like this (National Safety Council, 2013). The benefits of reporting near misses include the prevention of future incidents and promoting a safety culture (National Safety Council, 2013).
An important aspect of clarifying and refusing orders is adequate documentation.

Tips for Documenting
• Use quotation marks to document verbatim conversations with patients, families or other staff. Never use quotations when paraphrasing.
• Objective information only
• Describe in detail why you made the decision not to administer the medication or carry out the order
• Note who you notified and when, as well as their response
• If there is concern about another clinician’s unsafe practice, follow the organization’s chain of command, file an incident report (per hospital policy) but do not document in the medical record that an incident report was filed.

Perhaps there is another medication that can be administered to counteract a negative effect or the timing of the medication could be changed. Sometimes, we know that some medication’s benefits outweigh the risks. This underlines the importance of having open, honest discussions between physician, nurse, pharmacist and patient to determine the best plan of care.

Reflection Question #3:
You are visiting your family member who is hospitalized for post-operative complications. Your family member has a history of several chronic conditions. The nurse comes in and begins preparing a medication for your loved one. You ask, “What is that medicine for? What does it do?”
The nurse responds, “I’m not sure.”
Think about that. Have you ever witnessed this happening in your practice? Has it happened to you, maybe when you were a new nurse first starting out on the unit?

It is understandable, and common, that a physician may order a medication for a patient that the nurse is unfamiliar with. Maybe he/she is floating on a different unit or the medication is new. Or perhaps it is just an uncommon drug or a rare condition. The nurse then has the legal and ethical responsibility to find out what medication he/she is giving and why. Without understanding the drug’s purpose and possible side effects, how can the nurse monitor effectively for adverse events? How can he/she provide patient education? How can he/she evaluate whether or not the drug had its intended effect?

The Nursing Process
The nursing process dictates that nurses must evaluate all of their interventions in order to provide the best care.

4723-4-07 OAC:
5) Evaluation:
The registered nurse shall, in an accurate and timely manner:
(a) Evaluate, document, and report the patient’s:
(i) Response to nursing interventions; and
(ii) Progress towards expected outcomes; and
(b) Reassess the patient’s health status, and establish or modify any aspect of the nursing plan as set forth in this rule.

Error Reporting
Medication safety remains a National Patient Safety Goal by The Joint Commission (Agency for Healthcare Research and Quality, 2019).

Many medication errors go unreported out of fear or embarrassment (Okuyama, Wagner, & Bijnen, 2014). Research suggests that organizations are encouraged “…to develop a non-blaming, non-punitive and non-fearful learning culture at unit and organizational level. Anonymous, effective, uncomplicated and efficient reporting systems and supportive management behavior that provides open feedback to nurses is needed. All play a role in increasing the rate of reporting medication errors and near-misses amongst nurses” (Vrbnjak, Denieffe, O’Gorman, & Pajnkihar, 2016, p. 162). The ANA Code of Ethics, Provision 3.4, describes the nurse’s ethical responsibility to “promote patient health and safety” and “reduce errors”. It goes on to say that in the event of an error or near miss, the nurse has an obligation to report this per institutional policy and “must ensure responsible disclosure of errors to patients” (American Nurses Association, 2015, p. 11).

Provision 3.5 (Protection of Patient Health and Safety by Acting on Questionable Practice) states “Nurses must be alert to and must take appropriate action in all instances of incompetent, unethical, illegal, or impaired practice or actions that place the rights or best interests of the patient in jeopardy” (American Nurses Association, 2015, p. 12). In other words, although reporting “questionable practice, even when done appropriately, may present substantial risk to the nurse; however such risk does not eliminate the obligation to address threats to patient safety” (American Nurses Association, 2015, p. 13).

Medication Administration Safety
A 2017 study found that improper administration techniques related to asepsis and deviating from patient identification protocols accounted for most of the “medication administration-related deviations from safe practice” (Blignaut, Coetzee, Klopper, & Ellis, 2017). Researchers also found that interruptions during medication administration and patient acuity had a significant impact on the number of wrong-dose and wrong-route medication errors (Blignaut, Coetzee, Klopper, & Ellis, 2017). There have been innovations in making medication administration safer, including adding signage that medication preparation and/or administration is in progress and the nurse should not be interrupted (Pape, et al., 2005).These measures help improve focus and decrease distractions during critical times. As with any other safety measure, it will only work if nurses and other staff are compliant with the process.

A study published in 2019 found that “Nurses are able to identify medication errors, but are reluctant to report them. Fear of the consequences was the main reason given for not reporting medication errors” (Dirik, Samur, Seren Intepeler, & Hewison, 2019). Studies have shown that “speaking up training” to improve communication and encourage healthcare professionals to speak up did increase the comfort level of providers in speaking up as well as the act of “speaking-up behaviors” among staff (Okuyama, Wagner, & Bijnen, 2014, para. 15). What are some other reasons you can think of why a nurse would be reluctant to report an error? Are there processes in your organization for anonymous reporting?

A 2016 article published in the New England Journal of Medicine suggests that there should be a sixth right to medication administration: the right indication (Schiff, Seoane-Vazquez, & Wright, 2016).The article goes on to say that if indications are listed, “staff and patients will be able to more easily recognize any mismatches and intercept prescribing or dispensing errors” (Schiff, Seoane-Vazquez, & Wright, p. 306, 2016). They add, “knowledge of indications is key to getting prescribers, pharmacists, nurses, and patients on the same page regarding what is being treated and what outcomes are desired” (Schiff, Seoane-Vazquez, & Wright, p. 308, 2016). Regardless of whether or not the indication is explicitly listed, the nurse has the obligation to make sure he/she is aware of and understands that indication. It may take a few extra minutes on the part of the nurse, but those few minutes may save a life or prevent a very serious incident from occurring.

The nurse at the bedside using sound clinical judgement is key to safe medication administration. For both ethical and legal reasons, nurses must do their due diligence to give medications safely and document the care they are giving appropriately.
All of the technology in healthcare is only as good as those who operate it. If nurses are not properly trained on using the technology, if the process is too lengthy or too complicated, or if nurses do not see the value or importance of it, then compliance will be jeopardized. A culture focused on interpersonal accountability and safety above all else will be more effective in decreasing medical errors. Nurses need to speak up for safety and always remember the duty and responsibility that comes with the two letters after our names, R.N.

For more information, check out the Culture of Safety Webinar – Coming July 2019

Speaking Up for Safety: The Nurses' Role in Carrying Out Medication Orders

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Agency for Healthcare Research and Quality. (2019, January). Medication Errors and Adverse Drug Events. Retrieved April 2019, from Patient Safety Network: https://psnet.ahrq.gov/primers/primer/23/medication-errors-and-adverse-drug-events

American Nurses Association. (2015). ANA Code of Ethics. Silver Spring, Maryland: American Nurses Association. Retrieved from https://www.nursingworld.org/coe-view-only

American Nurses Association. (2016). Culture of Safety. Retrieved 2019, from ANA: https://www.nursingworld.org/practice-policy/work-environment/health-safety/culture-of-safety/

Anderson, P. (2015). Medication Errors: Best Practices. American Nurse Today. 10(9). Retrieved April 2019, from https://www.americannursetoday.com/medication-errors-best-practices/

Blignaut, A., Coetzee, S., Klopper, H., & Ellis, S. (2017, January 19). Medication administration errors and related deviations from safe practice: an observational study. Journal of Clinical Nursing, 26(21-22). doi:https://doi.org/10.1111/jocn.13732

de Raeve, L. (2002). Medical authority and nursing integrity. Journal of Medical Ethics, 28, 353-357. doi:http://dx.doi.org/10.1136/jme.28.6.353

Dirik, H., Samur, M., Seren Intepeler, S., & Hewison, A. (2019). Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing, 28(5-6), 931-938. doi:10.1111/jocn.14716
National Safety Council. (2013). Near Miss Reporting Systems. Retrieved April 25, 2019, from National Safety Council: https://www.nsc.org/Portals/0/Documents/WorkplaceTrainingDocuments/Near-Miss-Reporting-Systems.pdf

National Safety Council. (2013). Near miss reporting systems. Retrieved from https://www.nsc.org/Portals/0/Documents/WorkplaceTrainingDocuments/Near-Miss-Reporting-Systems.pdf

Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Services Research, 14. doi: 10.1186/1472-6963-14-61

Pape, T., Guerra, D., Muzquiz, M., Bryant, J., Ingram, M., Schranner, B., . . . Welker, J. (2005). Innovative approaches to reducing nurses’ distractions during medication administration. Journal of Continuing Education in Nursing, 36(3), 141-142. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16022030

Paradiso, L. (2018, March). Everyone is responsible for a culture of safety. American Nurse Today, 13(3). Retrieved from https://www.americannursetoday.com/everyone-responsible-culture-safety/

Patient Safety Network. (2019, January). Culture of safety. Retrieved April 2019, from Patient Safety Network: https://psnet.ahrq.gov/primers/primer/5/culture-of-safety

Reuter, C., & Fitzsimons, V. (2013, August). Physician Orders. American Journal of Nursing, 113(8), 11. doi:10.1097/01.NAJ.0000432941.27219.95

Schiff, G., Seoane-Vazquez, E., & Wright, A. (2016). Incorportating indications into medication ordering – Time to enter the age of reason. New England Journal of Medicine, 375(4). doi:10.1056/NEJMp1603964

Seidi, J., Alhani, F., & Ardalan, F. (2017). Exploring nurses’ experience about facilitating factors in medication administration based on clinical judgment of nurses: A content analysis. Electronic Physician, 9(12), 6063-6071. doi:10.19082/6063

Vrbnjak, D., Denieffe, S., O’Gorman, C., & Pajnkihar, M. (2016). Barriers to reporting medication errors and near misses among nurses: A systematic review. International Journal of Nursing Studies, 63, 162-178. doi:https://doi.org/10.1016/j.ijnurstu.2016.08.019