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Suggestions for resolving conflicts in drug therapy.



From the July 11, 2001 issue

Many serious medication errors reported to us have involved a drug order that at least one practitioner believed to be unsafe. In some cases, practitioners did not question the order because they felt intimidated by the prescriber. More often, practitioners questioned the order by discussing it with a supervisor, pharmacist or physician. Nevertheless, the practitioners' concerns were not addressed, the order was not changed, and the medication was administered in error. The missing link in preventing these errors is a clear process for handling drug therapy concerns which concludes only when all practitioners are satisfied that no harm will come to the patient. Although each process may vary to meet the unique needs of the organization, we recommend that you follow these guidelines for handling concerns and conflicts with drug therapy orders:

  1. If a nurse is concerned that physician-ordered drug therapy may not be safe, contact the pharmacist. This step is critical, especially when the drug ordered will be removed from unit stock or a patient's medication supply from home. The pharmacist must take an active role in determining the safety of the drug order and not delegate order clarification to nursing staff. Investigate the safety of the order and contact the practitioner as needed.
  2. If the pharmacist suspects that drug therapy is potentially harmful, he/she should pursue the matter until satisfied that the therapy will not harm the patient, or until the order is changed. Completely research the issue before contacting the ordering physician so your concerns can be clearly communicated and based on facts, not only your opinion. Confirmation of 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. Request supporting documentation (protocols, journal article, etc.) from the prescriber to verify the safety of the order but read it carefully. Many errors begin with the physician misinterpreting published information, misprints in texts, or ambiguous statements in the reference.
  3. If the pharmacist is not satisfied that the patient won't be harmed, and the prescriber will not change the order, consult with the prescriber's chief resident, chief attending physician, department chairperson or a specialist in the area of drug therapy ordered. If the individual consulted agrees that the order may be unsafe, have them contact the ordering physician.
  4. If concerns about drug therapy persist despite the above efforts, consider whether more significant harm would result from administering the drug than from withholding it. Refuse to dispense (or administer) the drug if you are reasonably sure that withholding the drug is the safest action. Refer the issue to an ad-hoc group for peer review to determine the order's safety.
  5. Do not request or allow the physician to give the drug himself or herself when a concern for patient safety remains unanswered. Patient safety is not served by attempting to transfer responsibility to the physician for any patient harm resulting from drug administration. There will likely be little legal or emotional absolution for the pharmacist or nurse if the patient is injured.
  6. Be sure to document your actions objectively on a standard incident report.
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