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Resolving human conflicts when questions about the safety of medical orders arise

From the March 13, 2008 issue

Many harmful prescribing errors that reach patients share a surprisingly common factor: at least one person—a healthcare practitioner, patient, or family member—felt there was a problem with the order before the medication was dispensed and administered. In some cases, healthcare practitioners or patients did not bring their concern to the attention of the prescriber because they were intimidated by the stellar reputation or disruptive behavior of the prescriber. They either assumed the prescriber knew more than they did or were afraid that if they were wrong, they would fall out of favor with the prescriber. In fact, in our 2003 survey on workplace intimidation, 40% of the respondents reported they had questions about the safety of an order in the past year but chose to assume the order was correct rather than interact with a prescriber they perceived as intimidating.(1)

In other cases, concern about the safety of a medication order was brought to the attention of another nurse, pharmacist, supervisor, or the prescriber. However, the person raising the concern was easily convinced that the medication was safe as prescribed. Sometimes, practitioners or patients moved forward despite a feeling that something was still wrong because they were unable to express the concern more clearly or the concern was not taken seriously by the prescriber. In the 2003 survey mentioned above, half of respondents said that when questioning the prescriber they felt pressured to dispense or administer the drug despite their concerns.

The missing link in preventing these errors is a defined process for handling drug therapy concerns which includes the provision that drug therapy does not move forward until all parties are satisfied that a safe resolution has occurred. A healthcare practitioner’s persistence in communicating recognized problems, even when met with opposition from experts, can clearly prevent harmful errors from reaching patients. Thus, an effective process for handling drug therapy conflicts requires more than a hierarchical structure of referring problems up the chain of command. Staff members need clear guidance and support from leaders of the organization to follow through when supervisors or those in authority, such as the prescriber, do not agree with their expressed concern. Although the process may vary to meet the unique needs of individual organizations, consider the guidelines below when developing or revising a process for handling conflicting opinions objectively and professionally.

Conflict Resolution Guidelines

Gather information. If a nurse or pharmacist suspects that an order is potentially harmful, he or she should pursue the matter until satisfied that the therapy is safe for the patient or until the order is changed. The nurse may contact a pharmacist to help research the issue before talking to the prescriber so factual information that supports the expressed concerns can be clearly communicated. The pharmacist or nurse might need to review the medical record, talk with the patient, use reputable drug information resources, and consult other nurses, pharmacists, or physicians to gather the information needed to communicate the drug safety concern effectively.

Question the order. Pharmacists and nurses should not be afraid to question an order when they have reason to believe a patient is at risk, or even if they just have     a sense that something is wrong. Practitioners who doubt their expertise should consider which would be worse: to be wrong, or to allow injury to a patient. Any questionable order should be discussed directly with the prescriber. Use of a standard communication strategy such as SBAR(2), as described below, can help frame the discussion.

(S)            Situation: Describe your concern about the safety of the medication order. 
(B)            Background: Provide pertinent information about the drug and the patient to further explain the basis of your concern.
(A)            Assessment: Offer your assessment of the potential harm that could occur to the patient if the medication is administered as prescribed, and how likely it is to occur.
(R)            Recommendation: Suggest the action you believe would make the medication order safe, or request its discontinuation. 

TeamSTEPPS(3) (Team Strategies and Tools to Enhance Performance and Patient Safety) is an evidence-based teamwork system that can also be adopted to improve communication among healthcare professionals.

If applicable, the pharmacist or nurse should ask the prescriber for documentation (e.g., protocols, journal articles) supporting the order and read any materials provided. The prescriber may have misinterpreted published information or used references that contain misprints. Statements such as “the protocol says to do it this way” or “that’s how they do it at University Hospital” should never be accepted as proof. These statements are “red flags”(4) signaling that the order needs further investigation. Check with risk management regarding the best way to document any safety concern and the prescriber's response to the concern.

Take the concern higher. If the prescriber will not change the order and the practitioner is not satisfied that the patient will not be harmed, the prescriber should not be asked, nor allowed, to personally administer the drug. Transfer-ring responsibility to the prescriber for possible patient harm is not likely to legally or emotionally absolve the practitioner if patient harm were to occur. Instead, the prescriber’s chief resident, chief attending physician, department chair, or a specialist in the area of the ordered drug therapy should be contacted. If that person also believes the order may be unsafe, he or she should contact the prescriber.

Refer to a peer-review group. If concerns persist despite these efforts, the nurse or pharmacist should consider whether greater harm would result from administering the drug than from withholding it. Practitioners should refuse to dispense or administer a medication if they are reasonably sure that withholding it is the safest action. The issue should then be referred to a timely ad hoc group for peer review to determine the order’s safety.

Call a rapid response team.(5) If patient wellbeing is likely to be compromised while peer review is undertaken, and the patient’s condition requires immediate attention, a rapid response team can be called if available (not all hospitals have established rapid response teams). The team can assist with recommending and taking emergency action as needed until the conflict about the safety of the order can be resolved. Upon admission, patients and family members also should be advised that they can call the rapid response team if they have time-sensitive concerns about medication use and believe their safety is in jeopardy.

Sadly, ISMP has heard from practitioners involved in fatal errors who live with regret because they did not follow through on a suspected problem. The lesson these practitioners want to share with all healthcare practitioners is to speak up and be persistent, even if there is just a hint of a potential safety issue. All practitioners involved in the medication-use system have an obligation to protect patients from harm. Following these guidelines when concern about the safety of a medication order arises can help fulfill that obligation.

References: 1). ISMP. Intimidation: practitioners speak up about this unresolved problem – part I. 2003 ISMP Medication Safety Alert! 9(5):1-3. 2). Kaiser Permanente of Colorado (Evergreen). SBAR technique for communication: a situational briefing model. Click here. 3) Agency for Healthcare Research and Quality. TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety. Available at: www.ahrq.gov/qual/teamstepps/. 4) ISMP. “Magic words” or “red flags?” 1999 ISMP Medication Safety Alert! 4(4):1-2. 5) ISMP. Rapid response team activation by patients can mitigate errors. 2006 ISMP Medication Safety Alert! 11(11):1-2.
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