Code of Conduct

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LABORATORY Health organizations are generally required to provide clinical laboratory services in order to address the care needs of their patients. They are responsible for the quality and timeliness of the services provided. There are a variety of highly specialized tests that healthcare organizations contract out to reference laboratories. Some organizations, such as nursing home facilities, because of limited financial resources contract with reference laboratories to provide routine lab testing services. Reference labs are often private commercial facilities that perform routine high-volume and specialty testing.

Laboratory medical technologists are expected to protect the welfare of patients and the tests conducted above all else. They are expected to avoid dishonest and unethical conduct. An organization’s laboratory provides data that are vital to a patient’s treatment. Among its many functions, the laboratory monitors therapeutic ranges, measures blood levels for toxicity, places and monitors instrumentation on patient units, provides education for the nursing staff (e.g., glucose monitoring), provides valuable data used in research studies, supplies data on the most effective and economical antibiotic for treating patients, serves in a consultative role, and provides important data as to the nutritional needs of patients.

Representation by a laboratory representative during routine patient rounds is noted by their absence, mostly because of the difficulty in determining the proper fit for such representation on an interdisciplinary patient care team. For sure, exclusion does not breed participation. A well-rounded educational experience should include exposure to the knowledge of the laboratory technologist, who provides a wealth of information in diagnosing, treating, and/or monitoring the progression or regression of illness. Lab tests provide invaluable information in:

identifying changes in health condition(s) before symptoms occur diagnosing or aiding in the diagnosis of a disease or condition planning treatment for a disease or condition evaluating a patient’s response to treatment monitoring the course of a disease over time

The value of laboratory medicine in patient care is unquestioned. A detailed study by the Lewin Group for the U.S. Centers for Disease Control and Prevention concluded that “laboratory medicine is an essential element of the health care system. It is integral to many clinical decisions, providing physicians, nurses, and other health care providers with often

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pivotal information for the prevention, diagnosis, treatment and management of disease.”

As noted in the following Reality Check, healthcare professionals can learn from the presence of a laboratory representative during case reviews.

Abnormal Laboratory Results Not Addressed

I was reviewing a patient record during the patient care conference and asked why the patient, Mrs. X, was admitted. The patient’s nurse replied, “The patient was diagnosed with an impending stroke.” Looking at the patient’s lab results, I said, “The patient’s glucose is high.” The nurse again replied, “Yes, but we are more concerned about the impending stroke.” I said, “I see the patient was admitted at 11:00 PM. Do you know when the patient ate last before her admission to the hospital?” The nurse, asking for and looking at the record, replied, “She ate last at 4:00 PM prior to her 11:00 PM lab results.” Looking at the laboratory manager, who was also a working laboratory technologist, I asked, “Is it normal for a patient who ate last at 4:00 PM to have an abnormally high blood glucose at 11:00 PM?” The laboratory manager replied, “It is not normal for it to be that high.” I followed up, “So the patient has been here three days, has there been any follow-up blood tests to determine if the blood glucose is back to normal?” The survey coordinator interrupted, “At the moment we are more concerned about the impending stroke.” I then asked, “Do you know if the patient has diabetes?” The nurse said confidently that the patient did not have diabetes.

I continued, “Looking at the history and physical, I see the physician wrote that the family medical history has been marked as unremarkable. Did your nursing assessment, care, and conversations with the patient reveal anything different as to the patient’s family history and the patient’s present condition? In other words, do you know if the patient might have a predisposition to a stroke based on the family history?” The nurse replied, “The parents died of natural causes.” I then asked to interview the patient if she agreed.

The nurse left the conference room to speak to the patient and shortly thereafter returned to the conference room and said, “Mrs. X said she was willing to talk to you.”

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After introducing myself to the patient and explaining my purpose for being at the hospital, I asked the patient about her care at the hospital. The patient said, “I am very happy with the care I am receiving at the hospital.” During our conversation I had the opportunity to ask about her parents. She explained how her father passed away as the result of a heart attack and her mother passed away as the result of a stroke. We talked a bit more on a happier note, and I thanked her for the opportunity to speak with her.

Returning to the conference room, I sat down with the staff and said, “My concern here is that the high blood glucose laboratory results were not addressed. The patient had other blood tests, but there was no follow-up on the one abnormal glucose reading. All the other tests were found to be normal. If the patient’s blood glucose is under control, the patient’s deficits will be less severe should her impending stroke result in a stroke. It should also be noted that abnormally high or low glucose readings could mimic the symptoms of a stroke. I am also concerned that the patient’s family history was written on the patient’s record as ‘Unremarkable.’

“I asked for the laboratory to have representation at this conference today. Technologists are rarely represented in these sessions, yet some have estimated that as many as 70% of medical decisions are based on laboratory results. Thank you for attendance here today.”

—Anonymous Patient Care Reviewer

Discussion 1. Should the responsibility of the laboratory end once the

results of diagnostic tests are provided to bedside caregivers? Discuss your answer.

2. Discuss how beside care can be more inclusive (e.g., teamwork through seamless education where patient- centered care can through case studies include representation by the various disciplines involved in patient care). Here the surveyor’s observations provide an opportunity to jointly discuss and review all aspects of patient-centered care.

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Ethics and Inaccurate Lab Results Ethics codes for both healthcare organizations and their professionals are written to protect patients as well as employees and their employers. The American Society for Clinical Laboratory Science, in its code of ethics states as to the duty owed to patients:

Medical Laboratory Professionals’ primary duty is to the patient, placing the welfare of the patient above their own needs and desires and ensuring that each patient receives the highest quality of care according to current standards of practice. High quality laboratory services are safe, effective, efficient, timely, equitable, and patient-centered. Medical Laboratory Professionals work with all patients and all patient samples without regard to disease state, ethnicity, race, religion, or sexual orientation. Medical Laboratory Professionals prevent and avoid conflicts of interest that undermine the best interests of patients.

Medical Laboratory Professionals are accountable for the quality and integrity of the laboratory services they provide. This obligation includes maintaining the highest level of individual competence as patient needs change, yet practicing within the limits of their level of practice. Medical Laboratory Professionals exercise sound judgment in all aspects of laboratory services they provide. Furthermore, Medical Laboratory Professionals safeguard patients from others’ incompetent or illegal practice through identification and appropriate reporting of instances where the integrity and high quality of laboratory services have been breached.

Medical Laboratory Professionals maintain strict confidentiality of patient information and test results. They safeguard the dignity and privacy of patients and provide accurate information to patients and other health care professionals. Medical Laboratory Professionals respect patients’ rights to make decisions regarding their own medical care.

Lab tests are not always accurate, sometimes due to human error or faulty test results. According to an article in the Baltimore Sun on March 11, 2004, approximately 640 patients at Maryland General Hospital may have received incorrect HIV and hepatitis test results. Some patients might have been told they were HIV-negative when in fact they were positive and vice

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versa, and the hospital failed to notify the patients of the problem. A former hospital employee had apparently filed a complaint. State health officials discovered in January that the hospital’s laboratory personnel overrode controls in the testing equipment that showed the results might be in error and then mailed them to patients anyway. Licensure and certification of laboratory staff are necessary in order to help prevent incidents of this nature. The American Society for Clinical Pathology, in a policy statement on State Licensure of Laboratory Personnel, Policy (Number 05-02), states:

Due to the complexity of laboratory medicine and its importance in quality patient care, it is imperative that medical laboratory personnel possess the qualifications necessary to ensure their professional competence. Licensure and certification programs not only set minimum standards for medical laboratory personnel working in clinical laboratories; they also help ensure quality laboratory testing and proper patient care.

Inaccurate lab tests are not uncommon occurrences and the headlines of inaccurate reporting continue to come to public attention, as noted in the next news clipping.

Spokane Woman Suing over False HIV Diagnosis

A Spokane woman is suing a Pennsylvania-based plasma donation company saying she was falsely told she had hepatitis and HIV after donating plasma at a clinic in Hayden, Idaho.

Melissa Bloom filed the lawsuit against BioLife Plasma Services alleging the clinic acted negligently when employees informed her she had the viruses after a combination of blood samples from several donors tested positive.

Bloom is seeking damages for emotional stress and punitive damages, saying she was informed of the positive test in April and went immediately to her doctor’s office for tests that determined she did not have the viruses.

—KOMONEWS.com, Associated Press, December 26, 2013

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Refusal to Perform HIV Testing Stepp, a laboratory staff technician, refused to perform tests on AIDS-contaminated fluids, a choice for which she was eventually terminated by the hospital. The Review Board of the Indiana Employment Security Division upheld the hospital’s decision to terminate the technician. The technician appealed the board’s decision. The Court of Appeals of Indiana, in Stepp v. Review Board of the Indiana Employment Security Division, held that the technician was dismissed for just cause and that the laboratory did not waive its right to compel employees to perform assigned tasks. The technician had been warned, suspended, and discharged for her refusal to perform the tests. She told her supervisors that she refused to perform the tests because “AIDS is God’s plague on man and performing the tests would go against God’s will.” The technician argued that that the employer hospital failed to provide a safe place to work. Under Section 11(c)(1) of the Occupational Safety and Health Act of 1970 (OSHA) an employer is prohibited from discharging any employee who exercises any right afforded by OSHA, which provides “the right of an employee to choose not to perform his assigned task because of a reasonable apprehension of death or serious injury coupled with a reasonable belief that no less drastic alternative is available.” The Supreme Court in Whirlpool Corp. v. Marshall laid out a two-part test. “First, an employee must reasonably believe the working conditions pose an imminent risk of serious bodily injury, and second, the employee must have a reasonable belief there is not sufficient time or opportunity either to seek effective redress from his employer or to apprise OSHA of the danger.” Stepp failed to successfully argue both parts of this test.

Although Stepp’s case involved legal issues for the courts to decide, there are a variety of moral issues for healthcare professionals to consider when refusing to perform tests that are required to determine a patient’s diagnosis. Of major applicability in this case is the principle of nonmaleficence—first, do no harm. Suppose for a moment that a technician was working alone at night on a weekend and was the only hospital employee who could perform cardiac enzyme blood tests to determine if the patient had a cardiac event. The blood sample arrives in the laboratory with an AIDS warning label attached. Should the laboratory technician refuse to perform the test, the legal and moral principles of ethics and applicable codes would not support the technician’s refusal to perform the tests so urgently needed to determine the patient’s treatment regimen.

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MEDICAL ASSISTANT A medical assistant is an unlicensed person who provides administrative, clerical, and/or technical support to a licensed practitioner. A licensed practitioner is generally required to be physically present in the treatment facility, medical office, or ambulatory facility when a medical assistant is performing procedures, but duties and scope of practice vary from state to state. Employment of medical assistants is expected to continue to grow over time. This growth is due in part to technological advances in medicine and a growing and aging population. Increasing use of medical assistants in the rapidly growing healthcare industry is expected to result in continuing rapid employment growth for the occupation.

Medical assistants work in physicians’ offices, clinics, nursing homes, and ambulatory care settings. The duties of medical assistants vary from office to office, depending on the location and size of the practice and the practitioner’s specialty. In small practices, medical assistants usually are generalists, handling both administrative and clinical duties. Those in large practices tend to specialize in a particular area, under supervision. Administrative duties often include answering telephones, greeting patients, updating and filing patients’ medical records, filling out insurance forms, handling correspondence, scheduling appointments, arranging for hospital admission and laboratory services, and handling billing and bookkeeping. Clinical duties vary according to state law and include assisting in taking medical histories, recording vital signs, explaining treatment procedures to patients, preparing patients for examination, and assisting the practitioner during examinations. Medical assistants collect and prepare laboratory specimens or perform basic laboratory tests on the premises, dispose of contaminated supplies, and sterilize medical instruments. They instruct patients about medications and special diets, prepare and administer medications as directed by a physician, authorize drug refills as directed, provide telephone prescriptions to a pharmacy, prepare patients for X- rays, perform electrocardiograms, remove sutures, and change dressings.

Medical assistants who work in the various medical specialties often have additional duties. Podiatric medical assistants, for example, make foot molds and assist podiatrists in surgery. Ophthalmic medical assistants help ophthalmologists provide eye care. They conduct diagnostic tests, measure and record vision, and test eye muscle function. They also teach patients how to insert, remove, and care for

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contact lenses. Under the direction of the physician, ophthalmic medical assistants may administer eye medications. They also maintain optical and surgical instruments and may assist the ophthalmologist in surgery.

Case Studies Looking for Help On July 12, Jill, who suffered so many years with neck surgeries, life-threatening infections, systemic sclerosis, and an ever-evolving number of physical symptoms requiring medical care—often poor best—developed severe pain in the left side of her head while at work. She was not speaking coherently and eventually lost consciousness for a few moments. She was taken to her physician’s office by a coworker. Jill’s physician ordered some tests at the hospital’s outpatient imaging center to rule out a transient ischemic attack (TIA). A medical assistant at the imaging center explained to Jill that her tests could not be scheduled until July 14.

Dan drove his wife Jill to her appointment. They arrived early on July 14 for her imaging test. On their arrival at the imaging center, Dan dropped Jill off at the front entrance while he searched for a parking space. Meanwhile Jill went into the center and handed her prescription to Carol, a medical assistant at the front desk. Carol said to Jill, “I am sorry, but we cannot perform your test. Your doctor faxed us an unsigned and undated order sheet. It is confusing as to what imaging studies he wants. He checked a box on the physician’s order sheet indicating that he wanted a CT scan of the head. In addition, there was a handwritten note on the form indicating that your physician wants an MRI to rule out a TIA. We are not sure if he wants one or both tests. You will have to get clarification from the physician as to exactly what procedure he wants.” Dan, after having parked his wife’s car, arrived at the front desk and saw his wife somewhat distressed. Carol explained the problem to Dan. He asked Carol, “Could you please contact the physician and ask him to clarify and fax back to the center what tests he wants?” Carol replied, “We are very busy; however, you can use our phone and ask the physician to clarify his order and have him fax us a new order.” Jill interrupted, appearing somewhat agitated, and asked, “What is your fax number?” Carol (pointing to a wall) replied, “It is posted there on the

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wall by the phone. You can use that phone.” Carol suggested to Jill that she complete the patient intake paperwork while Dan contacted Jill’s physician. Dan was able to get a new faxed order. As they waited for Jill to be called for her tests, with her eyes tearing up, she turned to Dan and said, “This is how my last 6 years of life have been … with so many health issues and hopelessly fighting to stay alive. What would I do without you?”

Ethical and Legal Issues 1. Should the medical assistant have clarified the physician’s

order prior to the patient’s arrival? Consider in your answer how Carol might have reacted if she was the patient, or her spouse, parent, or child was the patient.

2. Discuss what ethical issues you would be concerned with and what action would you take if you were a member of the governing body sitting in the waiting room observing this incident.

Case Studies Untimely Diagnosis The patient–plaintiff in Follett v. Davis discovered a lump in her right breast in the spring of 1988. She made an appointment to see Dr. Davis, her obstetrician/gynecologist, to see if she should be concerned about the breast lump she had discovered. The clinic had no record of her appointment. The clinic’s employees directed her to radiology for a mammogram. A technician examined the plaintiff’s breast and confirmed the presence of a lump in her right breast. Neither Dr. Davis nor any other physician at the clinic offered the plaintiff an examination. In addition, she was not scheduled for a physician’s examination as a follow-up to the mammogram. The plaintiff was instructed that she would hear from Dr. Davis if there were any concerns with her mammogram.

The radiologist explained in his deposition that the mammogram was not normal. Dr. Davis received and reviewed the mammogram report and considered it to be negative for malignancy. He did not know this was a new breast lump because none of the clinic employees had informed him about it. Neither clinic staff nor Dr. Davis contacted the plaintiff about her lump or the mammogram.

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The plaintiff called the clinic on April 6, 1990. She was told that there was nothing to worry about unless she heard from Dr. Davis. On September 24, 1990, the plaintiff returned to the clinic after she had developed pain associated with the same lump. A mammogram performed on that day gave results consistent with cancer. Three days later, Dr. Davis made an appointment for the plaintiff with a clinic surgeon for a biopsy and treatment. She kept her appointment with the surgeon. Nevertheless, this was her last visit with the clinic, as she subsequently transferred her care to other physicians. In October 1990, the biopsy confirmed the diagnosis of cancer.

In August 1992, the plaintiff filed a lawsuit. The evidence showed that after the patient found a lump in her breast, she went to Dr. Davis and clinic for help. Dr. Davis and the clinic, through the clinic’s employees and agents, undertook to treat her ailment. That undertaking ended when the clinic’s surgeon performed the biopsy and therefore was continuous in nature. The evidence demonstrated that had clinic procedures been followed, Dr. Davis or another physician at the clinic would have made a more timely diagnosis.

Ethical and Legal Issues 1. Describe the legal and ethical issues presented in this case. 2. Discuss what action the clinic’s leadership should take in

order to prevent similar incidents in the future.

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MEDICAL RECORDS Healthcare organizations are required to maintain a medical record for each patient in accordance with accepted professional standards and practices. The main purposes of the medical record are to provide a planning tool for patient care; to record the course of a patient’s treatment and the changes in a patient’s condition; to document the communications between the practitioner responsible for the patient and any other healthcare professional who contributes to the patient’s care; to assist in protecting the legal interests of the patient, the organization, and the practitioner; to provide a database for use in statistical reporting, continuing education, and research; and to provide information necessary for third-party billing and regulatory agencies. Medical records must be complete, accurate, current, readily accessible, and systematically organized.

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PHARMACY The practice of pharmacy essentially includes preparing, compounding, dispensing, and retailing medications. These activities may be carried out only by a pharmacist with a state license or by a person exempted from the provisions of a state’s pharmacy statutes. The entire stock of drugs in a pharmacy is subject to strict government regulation and control. The pharmacist is responsible for developing, coordinating, and supervising all pharmacy activities and reviewing the drug regimens of each patient.

Because of the immense variety and complexity of medications now available, it is impossible for nurses or physicians to keep up with all of the information required for safe medication use. The pharmacist has become an essential resource in modern hospital practice.

Medication errors are considered a leading cause of patient injury (FIGURE 9-2). Antibiotics, chemotherapeutic drugs, and anticoagulants are the three categories of drugs responsible for most drug-related adverse events. The prevention of medication errors requires recognition of common causes and the development of practices to help reduce the incidence of errors. With thousands of drugs, many of which look alike or have names that sound alike, it is understandable that medication errors are so common. The more common types of medication errors include prescription errors, transcription errors (often caused by illegible handwriting and improper use of abbreviations), dispensing errors, and administration errors. As noted in the following news clippings, medication errors are all too common occurrences.

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FIGURE 9-2 Prescription Errors Reviewed. © Scott Maxwell/LuMaxArt/Shutterstock, Inc.

Hospital Errors Common and Underreported

Sorrel King’s 18-month-old daughter Josie was recovering from second degree burns at Johns Hopkins Hospital in Baltimore when a communication breakdown caused a deadly misstep.

As King watched, a nurse gave Josie a methadone injection despite verbal orders to the contrary, assuring King that the order had been changed. Josie, who was about to be released from the hospital, went into cardiac arrest. “I took one look at her, ran into the hallway, and screamed for help,” King said. Josie died 2 days later. …

As many as one-third of hospital visits leads to hospital- related injuries, according to a report published today in Health Affairs.

—Katie Moisse, ABC News Medical Unit, April 7, 201180

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Drug Overuse Threatens Nursing Home Residents

More than five years after the federal government warned that drugs routinely prescribed to nursing-home residents posed serious threats, including an increased risk of death, inappropriate use remains high, according to a recent analysis by the American Society of Health-System Pharmacists (ASHP).

—Consumer Reports, December 2010

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Dispensing and Administration of Drugs The dispensing of medications is the processing of a drug for delivery or for administration to a patient pursuant to the order of a healthcare practitioner. It consists of checking the directions on the label with the directions on the prescription or order to determine accuracy; selecting the drug from stock to fill the order; counting, measuring, compounding, or preparing the drug; placing the drug in the proper container; and adding to a written prescription any required notations.

The administration of medications is the act of giving a single dose of a prescribed drug to a patient by an authorized person in accordance with federal and state laws and regulations. The complete act of administration includes removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container); verifying it with the physician’s order; giving the individual dose to the proper patient; and recording the time and dose given.

Licensed persons, in accordance with state regulations, may administer medications. Each dose of a drug administered must be recorded on the patient’s clinical records. A separate record of narcotic drugs must be maintained. The record must contain a separate sheet for each narcotic of different strength or type administered to the patient. The narcotic record must contain the following information: date and time administered, physician’s name, signature of person administering the dose, the balance of the narcotic drug on hand, and the proper recording of any drugs wasted/destroyed.

In the event that an emergency arises requiring the immediate administration of a particular drug, the patient’s record should be documented properly, showing the necessity for administration of the drug on an emergency basis. Procedures should be in place for handling emergency situations.

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Drug Substitution Drug substitution may be defined as the dispensing of a different drug or brand in place of the drug or brand ordered. “All states permit generic interchange to one extent or another.” Healthcare organizations use a “formulary system” whereby physicians and pharmacists create a formulary listing drugs used in the institution. The formulary contains the brand names and generic names of drugs. Under the formulary system, a physician agrees that his or her prescription calling for a brand name drug may be filled with the generic equivalent of that drug (e.g., a drug that contains the same active ingredients in the same proportions). When a formulary system is in use, the prescribing physician can request the use of a particular brand-name drug, when he or she deems it necessary or desirable for patient safety, by expressly prohibiting the use of the formulary system.

Hospitals are watchful for any abuses by physicians who circumvent the formulary for no valid, patient-safety reason. The ever-escalating costs of pharmaceutical products necessitates that hospitals become more vigilant in order to rein in costs.

Expanding Role of the Pharmacist Historically, the role of the pharmacist was centered on management of the pharmacy and accurate preparation and dispensing of drugs. The duties and responsibilities of pharmacists have, however, moved well beyond the scope of filling prescriptions and dispensing medications. Pharmacists do much more than this. They are increasingly playing an ever- expanding clinical role on various hospital specialty units (e.g., cardiology and oncology). They provide patient and staff education, consultation, and evaluation and selection of medications for placement in the hospital formulary; review medication errors; and report adverse drug reactions. Schools of pharmacy, recognizing the ever-expanding role of pharmacists in the clinical aspects of patient care, have raised the educational requirements for new graduates by requiring a Doctor of Pharmacy (Pharm.D.) degree.

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Duty to Monitor Patient’s Medications In Baker v. Arbor Drugs, Inc., a Michigan court imposed a duty on a pharmacist to monitor a patient’s medications. Three different prescriptions were prescribed by the same physician and filled at the same pharmacy. The pharmacy maintained a computer system that detected drug interactions. The pharmacy advertised to consumers that it could, through the use of a computer monitoring system, provide a medication profile of a customer for adverse drug reactions. Because the pharmacy advertised and used the computer system to monitor the medications of a customer, the pharmacist voluntarily assumed a duty of care to detect the harmful drug interaction that occurred.

Warning Patients About Potential for Overdose A Pennsylvania court held that a pharmacy failed to exercise due care and diligence because the patient was not warned about the maximum dosage of a medication. This failure resulted in an overdose, causing the patient permanent injuries. Expert testimony focused on the fact that a pharmacist who receives inadequate instructions as to the maximum recommended dosage of a medication has a duty to ascertain whether the patient is aware of the limitations concerning the use of the drug or, alternatively, to contact the prescribing physician regarding the inadequacy of the prescription.

Refusal to Honor a Questionable Prescription In Hooks v. McLaughlin, the Indiana Supreme Court held that a pharmacist had a duty to refuse to refill prescriptions at an unreasonably faster rate than prescribed pending directions from the prescribing physician. The Indiana Code provides that a pharmacist is immune from civil prosecution or civil liability if he or she, in good faith, refuses to honor a prescription because, in his or her professional judgment, honoring of the prescription would aid or abet an addiction of habit.

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Reducing Medication Errors Reducing medication errors requires an education process through college that includes not only pharmacists but must include physicians, nurses, and patients. A medication error is defined by the National Coordinating Council for Medication Error Reporting and Prevention “as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.”

Many errors occur as a result of poor oral or written communications. Enhanced communication skills and better interactions among members of the health care team and the patient are essential. The informed consent process should be used as a patient safety tool, and the patient should be warned about material and foreseeable serious side effects and be told what signs and symptoms should be immediately reported to the physician before the patient is forced to go to the emergency department for urgent or emergency care. Last, reducing medication errors is an ongoing process of quality improvement. Faulty systems must be redesigned, and seamless, computerized integrated medication delivery must be instituted by health care professionals adequately trained to use such technological advances.

The American Academy of Pediatrics issued guidelines to aid in reducing the number of medication errors in pediatricians’ daily practice.

Write prescriptions legibly, clearly, and unambiguously. Confirm the patient’s correct weight. Fully write out instructions about how to administer the drug; do not use abbreviations for dosage units or for the name of the drug. Avoid vague instructions; specify the exact dosage strength. Avoid the use of terminal zero to the right of the decimal point to minimize 10-fold dosing errors (e.g., use “5 mL” instead of “5.0 mL,” which could be misread as 50 mL). Use a zero to the left of a dose that is less than 1 to avoid 10- fold dosing errors (e.g., “0.1 mg” instead of “.1 mg,” which

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could be misread as 1 mg).

The physician’s goal to heal and do no harm mandates from both a legal and ethical perspective that physicians adopt and follow guidelines that help reduce the number of patient injuries associated with medication errors.

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PHYSICAL THERAPY Physical therapy is the art and science of preventing and treating neuromuscular or musculoskeletal disabilities through the evaluation of an individual’s disability and rehabilitation potential and the use of physical agents—heat, cold, electricity, water, and light—and neuromuscular procedures that, through their physiologic effect, improve or maintain the patient’s optimum functional level. Because of different physical disabilities brought on by various injuries and medical problems, physical therapy is an extremely important component of a patient’s total health care. As the following cases illustrate, there can be both ethical and legal issues when a therapist incorrectly interprets a physician’s orders for physical therapy.

Incorrectly Interpreting Physician’s Orders Richard J. Pontiff, in Pontiff v. Pecot & Assoc., filed a petition for damages against Pecot and Associates Rehabilitation & Physical Therapy Services and its employee Kim Morris. Pontiff alleged that Pecot and Associates had been negligent in failing to properly train, supervise, and monitor its employees, including Morris, and that Pecot and Associates was otherwise negligent. Pontiff alleged that employee Morris failed to exercise the degree of care and skill ordinarily exercised by physical therapists, failed to heed his protests that he could not perform the physical therapy treatments she was supervising, and failed to stop performing physical therapy treatments after he began to complain he was in pain. Pontiff claimed he felt a muscle tear while he was exercising on the butterfly machine, a resistive exercise machine.

Pontiff’s expert, Patricia Boulet, a licensed practicing physical therapist, testified that Mary Pecot, the clinic’s owner, deviated from the standard of care of physical therapists by introducing a type of exercise that, according to her, was not pre

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