Suggestions for Resolving Conflicts in Drug Therapy

16 May
2010

PROBLEM: Many serious medication errors that have been reported to the Institute for Safe Medication Practices (ISMP) have involved drug orders that were considered by at least one practitioner to be unsafe. In some cases, the practitioners did not question the orders, because they were reluctant to challenge the prescriber. More often, the practitioners questioned the orders by discussing them with a supervisor, pharmacist, or physician. Nevertheless, the practitioners’ concerns were not addressed, the orders were not changed, and medications were administered in error.

SAFE PRACTICE RECOMMENDATION: The missing link in preventing these errors is a clear and effective process for handling concerns about drug therapy; this process concludes only when all practitioners are satisfied that no harm will come to patients. In fact, the ISMP has received many reports of lethal errors in which drug orders were questioned but not changed. Apcalis Oral Jelly

Institutions should develop a process that clearly specifies the steps for practitioners to take to resolve drug therapy conflicts. The American College of Physicians Ethics Manual states that all members of the patient-care team have equal moral status. When a health care professional has major objections to an attending physician’s order, both of them are obligated to discuss the matter thoroughly and mechanisms must be available in hospitals to resolve differences of opinion among members of the team. All staff members should feel that the process is workable and effective. Although each process may vary to meet the unique needs of organizations, the following guidelines should be implemented for handling concerns about drug therapy orders:

1. If a nurse thinks that a physician-ordered drug therapy might be unsafe, he or she should contact the pharmacist. This step is critical, especially if the drug to be ordered will be removed from unit stock or from a patient’s medication supply from home. The pharmacist must take an active role in determining the safety of the drug order and must not delegate the task of clarifying the order to the nursing staff. The safety of the order should be investigated, and the practitioner should be contacted as needed.

2. If a pharmacist suspects that a particular drug therapy might be harmful, he or she should pursue the matter until it is evident that the treatment will not harm the patient or until the order is changed.

a. The pharmacist should research the issue completely before contacting the ordering physician so that concerns can be clearly communicated and based on facts, not only on opinion. Confirming an order’s safety may come from reviewing the medical record, talking with the patient, researching the matter through reputable drug resources, consulting with other pharmacists or physicians, or discussing the order directly with the prescriber.

b. The pharmacist should request supporting documentation (e.g., protocols or journal articles) from the prescriber to verify the safety of the order and should read it carefully. Many errors occur because a physician has misinterpreted published information, misprints in texts, or ambiguous statements in references.

3. If the pharmacist still thinks that a patient might be harmed, and if the prescriber will not change the order, the pharmacist should consult with the pre-scriber’s chief resident, the chief attending physician, the department chairperson, or a specialist in the drug therapy that has been ordered. If the individual consulted agrees that the order might be unsafe, he or she should be requested to contact the ordering physician.

4. If the pharmacist’s concerns persist despite these efforts, he or she should consider whether more significant harm would result from administering the drug than from withholding it. The pharmacist should refuse to dispense (or administer) the drug if he or she is certain that withholding the drug would be the safest action. The problem should be referred to an ad hoc group for peer review to determine the order’s safety. canadian pharmacy generic viagra

5. The physician should not be requested or allowed to administer the drug when the question of patient safety remains unanswered. Safety is not served by attempting to transfer responsibility to the physician for any possible harm to the patient that results from drug administration. If a patient is injured, there will probably be little legal or emotional absolution for the pharmacist or nurse.

6. All actions should be objectively documented on a standard incident report.

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