Nursing Law & Order

CNN coverage on the Doctor Shortage and the use of Nurse Practitioners

http://money.cnn.com/galleries/2009/news/0907/gallery.healthcare_nurses/index.html

Anesthetic Agent Diprivan and the American Association of Nurse Anesthetists statement

For Immediate Release
July 9, 2009

Turning a Harsh Spotlight on Propofol Misuse 
Dangerous drug linked to Michael Jackson sparks concern over abuse potential and non-anesthesia professionals providing to patients 

How unfortunate that it took the tragic death of a famous celebrity to sound the alarm on propofol, a potentially dangerous anesthetic drug that can turn deadly when used for the wrong purpose or administered by anyone other than a qualified anesthesia professional.

Used as intended—for surgical or diagnostic procedures conducted in an appropriate healthcare setting by a qualified anesthesia professional such as a Certified Registered Nurse Anesthetist (CRNA) or physician anesthesiologist—propofol is fast-acting, short-lived, and very safe. But when used for other purposes, in other settings, by anyone other than a CRNA or anesthesiologist, the risks can be significant. Unfortunately, until now regulatory agencies, insurance companies, and various non-anesthesia professionals have downplayed the dangers of propofol, virtually treating its use as “so easy, anyone can do it!” It is far from that.

The American Association of Nurse Anesthetists (AANA), representing 40,000 members who deliver more than 30 million anesthetics to patients each year, has taken a strong stance on the dangers of propofol misuse. Through extensive lobbying, testimony, and education, the AANA has continually emphasized two main concerns.

First, propofol can be very addictive. Abuse of the drug is becoming more common among anesthesia professionals and other healthcare providers who have easy access to it. To help address this growing concern, on June 22—just days before the media exploded with reports linking alleged propofol use to pop star Michael Jackson—the AANA became the first anesthesia professional association to publish a position statement, recommending that healthcare facilities keep propofol in a secure environment to reduce the risk of its diversion and abuse by providers. Patients, however, should not needlessly worry about becoming addicted after receiving propofol for a surgical or diagnostic procedure. The risk of this happening is the same as with any other anesthesia/sedation drug received for these purposes—miniscule.  Patients who have questions or concerns about their anesthesia care should never hesitate to ask their anesthesia professional during their preoperative consultation.

Second, the package insert for propofol, which is approved by the U.S. Food and Drug Administration (FDA), requires that the drug be administered by healthcare professionals trained in the administration of general anesthesia—in other words, CRNAs and anesthesiologists. Despite the fact that a patient sedated with propofol can slip into general anesthesia and stop breathing, this potentially dangerous drug which has no antidote is administered in many outpatient facilities by healthcare providers other than CRNAs or anesthesiologists, particularly for colonoscopies and related procedures. Even though mishaps  are rare, would you want a loved one to be sedated with this powerful drug by  someone who is not trained to recognize all the signs and symptoms of general anesthesia, and who is not an expert in patient rescue in the event of drug overdose and emergency?

So why then is this allowed to happen? One big reason should come as no surprise: Insurance companies are not reimbursing for propofol delivery by anesthesia professionals for diagnostic procedures such as colonoscopies because it is considered to be too expensive. Patient safety and comfort, which should be the real drivers of healthcare practice, once again are merely an afterthought.

The AANA and the American Society of Anesthesiologists feel so strongly about this risky business that the two organizations published a joint statement (http://www.aana.com/jointstmt_propofol.aspx) in 2004 stating that whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia and who are not simultaneously involved in the surgical or diagnostic procedure. The statement adds emphatically that “failure to follow these recommendations could put patients at increased risk of significant injury or death.” Consistent with the joint statement, on May 28, 2009, the AANA testified at an FDA hearing that propofol administered by healthcare providers who are not expert in general anesthesia, resuscitation, and the use of emergency equipment is highly dangerous.

The bottom line is that propofol is not a sleep aid, is not for recreational use, and is potentially addictive and dangerous in the wrong hands. While the reason for the sudden interest in propofol is indeed sad, we can only hope that the long-overdue attention now being paid to this drug will lead to heightened awareness of its high abuse potential and an increased adherence to the FDA requirement that it be administered only by those qualified to do so.

http://www.aana.com/News.aspx?ucNavMenu_TSMenuTargetID=62&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=22278

Psych Patient charged with Felony Assault for Hitting an Ohio Nurse

http://www.wpri.com/dpp/news/local_news/local_wpri_warwick_kent_patient_accused_of_assaulting_nurse_060209_acm

What do you think? Should patients who hit nurses face criminal charges?

Soap on the Rope: Medication Errors, Patient Injury or Death, and the Nurse. But what about Magnet?

A number of factors can contribute to a medication error(s) in a hospital. It is interesting to see how some hospitals handle a medication error(s), which caused or contributed to patient harm or death; the discipline slopes downhill.

I have been contacted by four nurses this year who work in hospitals and who have been involved in serious medication errors. Two of the cases involved a patient death and two involved serious injury.

None of the nurses have their own professional liability insurance policy with a license defense benefit. Do you know how scary it is to be in this type of situation? You don't realize how bad you need your insurance policy until something like this happens. This is the kind of stress that leads hair loss, bleeding ulcers, mind numbing headaches, and taking a combo of meds everyday to remain functional.

You are flying blind so please take your blinders off because your interests may not be the same as the interests of the Hospital in the forthcoming litigation.

Did you know that nurses are sued individually and named as defendants in med mal and negligence cases? See the NSO RN Claims Study. https://www.nso.com/pdfs/db/rnclaimstudy.pdf?fileName=rnclaimstudy.pdf&folder=pdfs/db&isLiveStr=Y&refID=rnstudy

What's even more interesting is some hospitals, depending on where the hospital is in the Magnet process, leave the nurses dangling like soap on a rope. Maybe we will report it to the Nursing Board, but what about Magnet? Maybe we will self report to JCAHO, but what about Magnet? What if this is leaked to the media and the press, what about Magnet? Should we apologize to the family and settle outside of litigation, what about Magnet?

Hospitals have insurance and are prepared for lawsuits so therefore its not the lawsuits that keep the C-Suite officers at up a night in these types of cases. Hospitals have a team of lawyers ready and willing to investigate and litigate these cases.

What about Magnet is the million dollar question, not what about the nurse?

Guess what if you don't have your own professional liability insurance policy and you are involved in a serious or medication error(s), then you are going to need a heap of cash, baby. Why?

You may need your own personal counsel in the medical malpractice case (can you say evergreen retainer and $250.00 an hour for attorney fees depending on the law firm?) and you will most certainly need attorney representation when this is reported to the State Nursing Board.

Or you can do what most nurses do anyway: follow the advice and counsel of the hospital management, risk management, and attorneys, not seek independent legal advice and continue to be the soap on the  rope. Its only your nursing career, your license, your livelihood, your life, and your assets.

Ohio Medicaid Waiver Program-OHPCAN Alert

July 02, 2009   Help Save Ohio's Waiver Programs   While state programs adjust to the 70% funding levels of the 7-day interim budget, lawmakers turn their attention back to figuring out where they can find dollars to fill the $3 billion hole in the biennial budget. Waiver programs, considered optional under Medicaid, are being eyed as possible sources of revenue.  You heard that right-legislators are looking heave the budget burden onto the shoulders of Ohio's disabled and elderly citizens. CALL YOUR LEGISLATOR TODAY AND TELL HIM/HER  THAT WAIVER PROGRAMS, LIKE PASSPORT AND THE OHIO HOMECARE PROGRAM, ARE VITAL TO THE HEALTH OF VULNERABLE OHIOANS. Mention that: ·         Home care has been shown to save tens of thousands of dollars annually per beneficiary, since home care costs only a fraction of what facility-based care costs. ·         People will still seek care if they do not receive supportive services, but they will seek it in costlier settings. This will result in higher rates of hospitalizations, increased enrollment in costlier settings such as nursing facilities, and increased reliance on already-strained informal caregivers. ·         The Ohioans most likely to be hurt by cuts to waiver programs are the most vulnerable Ohioans: those suffering chronic debilitating disease or those coping with long-term disability. Your patients need you right now to be their advocate. Call your state Representative and Senator TODAY to tell them how important waiver programs are to the most vulnerable Ohioans.  You can find your legislators' phone numbers by visiting  http://www.legislature.state.oh.us/ and using the "Locating Legislators" tool for your home address. Please call them rather than writing or emailing.   It is the only way to guarantee your message is heard by a real person who can communicate the importance of hospice to your legislator. It is particularly important if your Representative or Senator is one of the Conference Committee members, since they will have the most direct impact on the budget negotiations. Conference Committee members are: Governor Ted Strickland                614-466-3555  Senator John Carey                        614-466-8156  Senator Dale Miller                        614-466-5123  Senator Mark Wagoner                  614-466-8060  Senator Tom Niehaus                     614-466-8082  Representative Vernon Sykes        614-466-3100  Representative Ron Amstutz         614-466-1474  Representative Jay Goyal              614-466-5802  Representative Linda Bolan          614-466-8022 On behalf of the Ohio Home, Hospice & Palliative Care Advocacy Network, thank you in advance for your commitment and advocacy for those Ohioans facing serious illness.  Please contact Susan Wallace, Public Policy Coordinator by emailing [email protected] if you encounter any difficulties, or if you need additional information or support.  ©2009 Ohio Hospice & Palliative Care Organization Ohio Home Care Organization 555 Metro Place North, Suite 650 :: Dublin, Ohio 43017-1375 (614) 763-0036 :: 1-800-776-9513 :: fax (614) 763-0050

To send to a friend, click here.

Certified Medication Aides and the Brick Wall for Nurses: Delegation is an Academic Exercise for Folks Like Me, Not for those at the Bedside

I have remained quiet about certified medication aides in long term and the role of nurses in this process. I was skeptical (that's my nature) but waited to see what would evolve.  

The Ohio Board of Nursing in the Spring 2009 Momentum has an excellent article, Delegation of Medication Administration to Medication Aides in Nursing.

The way job description are written in long-term care and patient care assignments are made there is no true delegation. Nursing homes in my opinion and how they are managed have attributed to the failure for most to understand the distinctions between the RN scope of practice and the LPN scope of practice because patient care is scheduled by halls, units, etc.

Now here comes the certified medication aides and nurses are utimately accountable and potentially liable for the failure to delegate in accordance with the Nurse Practice and Regulations. That's nice. Most of us are nurses are not comfortable with delegation because healthcare is provided along the lines of job descriptions and patient care assignments for efficiency and the role of the RN in delegation has become academic.

Academic meaning folks such as myself (who are not at the bedside) will research and publish on the delegation but the real world application of delegation in daily clinical practice requires a firm grasp on the Nursing Board law and rules, employer policies and procedures, and the job descriptions, scope of practice, and roles of RNs, LPNs, and Certified Medication Aides. How many employers are providing this type of intense inservicing and training on delegation? Exactly.

I can understand the rationale and economics driving the use and regulation of certified medication aides, but if you are going to create a new class of paraprofessionals who can administer medication, let those individuals be exclusively accountable, responsible, and potentially liable for their actions without adding nursing delegation to the mix. I also understand there is a need for other licensed or regulated paraprofessionals to do some of the tasks traditionally associated with nursing for a variety of reasons, but damn.

Nurses are already assuming too much risk and potential liability in healthcare without adequate safeguards to manage the risk and the sad part is the majority of us are not aware of this risk and legal liability until we hit the brick wall at 90 mph.

I know the use of certified medication aides in expanding with several states already having aides purportedly with low medication error rates, but we do things differently here in O-Hi-O and things that work in other states for some reason don't work here, so I would like to see if plaintiff attorneys bite at this in Ohio nursing home negligence case (again things that folks like me monitor who are not at the bedside) or what types of Ohio Nursing Board complaints and discipline for RNs and LPNs not delegation in accordance with the law and rules (folks like me monitor this as well) will follow this.

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Home Health: The Final Frontier for Risk, Potential Liability, and State Nursing Board Complaints

The Final Frontier is from Star Trek and I hope by now you have seen the new Star Trek.

I loved working as a home health RN and I plan to transition back into home care at some point in the future. Maybe just a few visits per month just to keep my skills current. But guess what? I have been out of the thick of it for over a year and I will need to be reoriented, shadow another nurse for several days, and have some classroom and lectures components before working as a home health RN again. I will need a longer orientation period (which I am willing to do uncompensated if needed because I will be working per diem not full time or part-time) because its my license on the line when I am caring for patients and performing visits.

I am seeing more home health cases in my law practice where home health nurses are being reported to the State Nursing Board for professional boundary issues, billing discrepancies, fraudulent documentation, theft of patient property, unsafe nursing practice, drug theft and diversion, misconduct/unprofessional behavior, CPR issues, etc.

If you are planning to transition to home care make sure you have the training and orientation you need before you make the leap. There is more autonomy and less supervision in home care as opposed to working in a hospital or other healthcare settings. Having more autonomy and less supervision has legal risks.

Are you ready to manage those legal risks because you are responsible and accountable for your nursing practice? Its your license; your nursing license does not belong to the patient, family, or the home care agency.

If you are a home health nurse and you practice in Ohio, Kentucky, and Indiana and you are "willy nilly" in the field; I am expecting your phone call (sooner or later) and I am looking forward to working with you.

You would not walk a tight rope two stories in the air without a net, would you?

You would not dive in a concrete swimming pool head first without water, would you?

You would not eat your mother in law's cooking without taking Gas-X and Tagamet, would you?

Of course not, so don't assume the care for high acuity and complex home care patients on the skilled or private duty side without the proper training, orientation, and in-servicing.

I wish I could apply for this position!

The Little Clinic

General Information (109264)

Job title: Family Nurse Practitioner Job location: Cincinnati, OH  45255 United States Requisition code: Date posted: 01/29/09 Job type: Full-Time Compensation: Job Classification Job category: Family Practice Nurse

Job Description

Job description:

The Little Clinic provides Family Nurse Practitioners with a work environment focused on quality healthcare - where you make patient care decisions because you have the latitude in diagnosing and prescribing the care for your patients using evidence-based medicine to create a superior customer experience. We offer a Rewarding Career beyond the Traditional Practice Setting • Work in a friendly, community service-oriented retail grocery chain in your neighborhood. • Opportunity to educate patients and to provide the highest possible quality of care. • Professional autonomy with more independence to make patient care decisions. • Outstanding benefit & compensation package with incentive pay available. • Ability to establish strong patient relationships. • Flexible schedules. We currently have openings at the following clinics located in our Cincinnati, OH region: • 6950 Miami Ave., Maderia, OH • 5100 Terra Firma Dr., Mason, OH • 5830 Harrison Rd., Cincinnati, OH • 7580 Beechmont Ave., Cincinnati, OH • 11390 Montgomery Rd., Cincinnati, OH

Job Requirements

Education, training, experience:

• Masters of Science in Nursing (MSN) as Family Nurse Practitioner. • Active license, AANP or ANCC certification and credentialing in the state in which he/she will be working required. • One year experience as a NP. • Excellent telephone, interpersonal and organizational skills; ability to prioritize. • Good computer skills. • Ability to travel within the region 10%. ------------------------------------------------------ http://ona.associationcareernetwork.com/JobSeeker/JobDetail.aspx?abbr=ONA&jobid=7012ef74-06b9-4cad-bc2c-1f91e791ce1e&stats=y&stats=y&utm_source=NURSES.OH%2BJob%2BFlash%2B1%2B2009-03-3&utm_medium=Email

Midwife Advocates Challenge the Status Quo

See this article that appeared in the Cincinnati Enquirer. It should come as no suprise as some doctors are resistant to home births with certified nurse midwives let alone lay midwives.

Cut and paste of part of the article:

The states are now evenly split on legal recognition of certified professional midwives (CPMs) - those who lack nursing degrees and who account for most midwife-assisted home births.

Half the states have procedures allowing CPMs to practice - including five which have taken such steps since 2005. The other 25 - including Ohio and Kentucky - lack such procedures and CPMs are subject to prosecution for practicing medicine without a license.

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What do you think about the use of certified nurse midwives (CNM) vs. certified professional midwives (CPM)?  

http://news.cincinnati.com/apps/pbcs.dll/article?AID=/20090129/LIFE07/901290347

With increased autonomy comes increased responsibility, accountability, and potential liability. Are we ready?

See this article.

http://www.mycentraljersey.com/article/20090102/NEWS/901020350/1003/newsfront

Barbara DiCicco-Bloom is quoted as saying "The thing that needs to change for nurses is the respect they have. There's a need for them to have the authority, the autonomy and the capacity to really meet their potential as a professional, which I think, in the end, would be very beneficial for patients," she said. "Every paper that I've written has that at its core."

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With the increased authority and autonomy, an increase in accountability, responsibility, and potential liability follows. 

Is the profession ready for the increased accountability, responsibility, and potential liability that flows from increased authority and autonomy in your opinion?  

As a licensure defense attorney on the front line and in the battlefield with cases involving licensure, employment, regulatory, criminal, and civil implications, my answer may differ from your answer.

Opening Pandora's Box: Investigations of Controlled Substance Discrepancies

A pharmacist in a hospital and law enforcement investigation of nurse for Pyxis discrepancies related to controlled substances mentioned Pandora's Box.

I am sure you are familiar with Pandora's Box. http://en.wikipedia.org/wiki/Pandora's_Box

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http://drugtopics.modernmedicine.com/drugtopics/article/articleDetail.jsp?id=326263

Here is the cut and paste of the article:

Software helps hospitals deal with narcotics theft

Publish date: May 22, 2006
By: Charlotte LoBuono
Source: Health-System Edition

Pandora Data Systems recently released a multi-user, Health Insurance Portability & Accountability Act (HIPAA)-compliant version of its medication usage analysis software. Designed in 1989 in partnership with a local pharmacist to be used in conjunction with his Pyxis 1000 automated dispensing system (ADS), the current version of Pandora is compatible with the Pyxis 3000 and the McKesson AcuDose and Omnicell dispensing systems as well.

Pandora Clinical Data Comments Report

"We have a suite of reports that sound an alarm, about possible incidents of drug diversion," said David Cree, sales director for Pandora Data Systems. "For example, our Anomalous Usage Report uses colored bar charts to 'highlight' users whose withdrawals of narcotics from the ADS lie outside the norm. After the report is run, a 'hot list' of potential diverters can be created." He added that the reports generated by Pandora are "pre-designed with the pharmacist and pharmacy director in mind. The information is already sorted in a way that allows pharmacists to access the information they need."

Dan Vineyard, a customer advocate for Pandora, noted that Pandora reports are evidentiary grade reports that organizations such as the Food & Drug Administration, Federal Bureau of Investigation, Drug Enforcement Administration, and Joint Commission on Accreditation of Healthcare Organizations can request by name. State pharmacy and nursing boards also request documents generated by Pandora, he said.

Gregory Sophis, R.Ph., MBA, director of pharmacy at Mount Auburn Hospital, Cambridge, Mass., further explained that "if a hospital does, say, a million transactions per year on a Pyxis ADS, you must be able to closely analyze all of those data. Pandora does this in a few simple keystrokes."

Data analysis is important for catching diverters, according to Sophis. While there is other drug diversion software available on the market, Pandora's version allows virtually unlimited data storage, whereas some competing products store data for only 30 days.

Patty Womack, Pharm.D., the lead clinical pharmacist at the Community Hospital of San Bernardino in California, commented, "The big advantage with Pandora is that it makes sorting through data very easy," she said. "We have been using Pandora for three to four years. Before that, any evidence of drug diversion was largely anecdotal."

Once those who remove more medication than others from the ADS have been identified, Pandora provides the tools needed to investigate where those drugs are going, said Vineyard. "Pandora is good at uncovering the many different methods diverters use. For example, every discrepancy that gets resolved must have a witness. Often addicted professionals work together by witnessing each other's resolutions and then splitting the drugs."

Cree explained that Pandora has a discrepancy manager. "Once you have flagged persons with anomalous usage, you can start to look at their discrepancies and determine if the resolutions are acceptable and if discrepancies are indeed one of the routes by which they divert."

Pandora allows users to detect and document diverters at any level of responsibility within the hospital, said Cree, because the software can be installed facilitywide. He also said that it has the ability to automatically generate and send different reports to selected users. So, for example, financial reports can be sent to the chief financial officer and discrepancy reports can be sent to nurse managers.

Cree said the scope of these reports allows for a broader delegation of responsibility to a wider range of people, and the more people who are involved in preventing diversion, the more effective their efforts are.

Prior to Pandora, pharmacy directors were solely responsible for detecting drug diversion and acting upon it, Cree continued. He said that by providing nurse managers and other department directors with data for the professionals they supervise, Pandora becomes an accountability and delegation tool in the hands of pharmacy directors.

"Pandora software is a huge saver of time, money, and manpower," Sophis concluded. "This is significant, because drug diversion is more common than most people want to believe."

THE AUTHOR is a writer based in New Jersey.

2008 Indiana Board of Nursing Advanced Practice Nurse Subcommittee Recommendations

See http://www.in.gov/pla/files/2008_Final_APN_Subcommittee_Recommendations.pdf.

Ohio Board of Nursing Committee on Practice next meeting is Jan. 15, 2009

Board Committee on Practice Meeting
January 15, 2009

The Board of Nursing is convening a Board Committee on Practice at 12:00 p.m. Thursday January 15, 2009, at the Board offices located at 17 South High Street, Suite 400 in Columbus. The Board Committee, chaired by Vice President J. Jane McFee, LPN, will begin its review and discussion of Chapter 4723-17 OAC, Intravenous Therapy Courses for Licensed Practical Nurses. This chapter of the administrative rules is available for review and download from the Board of Nursing website: www.nursing.ohio.gov in the "law and rules" section. The rules are listed in numerical order.

The Board Committee on Practice, comprised of Board members, is a public meeting convened by the Board on an as needed basis to review and discuss practice issues and to make recommendations to the Board for its consideration.

See the Board's website at http://www.nursing.ohio.gov/.

Ohio CRNAs cannot write orders for RNs and LPNs to administer medications

See the correspondence from the Ohio Board of Nursing Practice Manager to OSANA, the Ohio State Association of Nurse Anesthetists.

You will see from reading the correspondence that there was some confusion and debate as to whether this was in the scope of practice of Ohio CRNAs.

http://www.nursing.ohio.gov/PDFS/NextMeeting/M1/6.1LetterOSANA.pdf

Botox and Ohio Nurses: This is only the beginning

Thank you Pat for emailing me this link.

What are the standards in your state related to Botox administration?

Do you see this as a victory for the expansion of the nursing scope of practice, an assumption of more legal risks, a case of employers asking nurses to "do more" but not increasing salary, or something else?

http://www.dispatch.com/live/content/business/stories/2008/08/17/Botox.ART_ART_08-17-08_D1_9CB1E66.html?sid=101

Here is the cut and paste:

 

Nurses can give Botox injections

But the procedure still must be done in physician's office

Sunday,  August 17, 2008 3:46 AM

By Marcey Goulder

 

Crystal Ford gets Botox injections to deal with wrinkles. "I tell everyone I'm growing old gracefully, just cheating along the way," she said.

Botox is booming, here and abroad.

And thanks to a ruling by the Ohio Board of Nursing, the wrinkle-smoothing toxin is likely to help some Ohio medical practices improve their own lines -- their bottom lines.

Last week, Allergan Inc., the pharmaceutical company that makes Botox, said its second-quarter profit rose 6.9 percent, well above analysts' estimates, largely because of robust sales of the facial treatment overseas. Overall, Botox sales jumped 13 percent, to $315.5 million.

A survey by the American Society for Dermatologic Surgery suggests that the use of Botox and dermal fillers is up in the United States, too, in spite of -- or perhaps because of -- the sagging economy and rising unemployment. In a news release detailing the findings, the organization speculated that "baby boomers may be looking to put their best face forward on the interview circuit."

In Ohio, Botox sales could get an additional boost from the recent determination that nurses can give Botox injections, provided that they first undergo special training.

The financial advantage is obvious: By assigning the duty to nurses, medical practices that offer Botox can treat -- and bill -- more patients. And because health-insurance plans typically don't cover elective cosmetic procedures, practices can deal directly with patients and charge, for the most part, whatever the market will bear.

In 2006, the most recent year for which data are available, physicians across the country charged an average of $492 for a Botox injection, according to the American Society of Plastic Surgeons.

Because Botox is a poison, some states explicitly forbid anyone other than a licensed physician to administer the drug.

Before the nursing board ruled on the matter last month, however, Ohio's nurses were operating in uncharted territory. Some were giving Botox shots -- and even determining doses. Others thought the procedure was beyond the scope of practice for nurses and therefore could be performed only by a physician.

"There was no specific prohibition," said Lisa Emrich, manager of the board's nursing practice, education and administrative unit. "It was becoming evident that physicians wanted nurses to do this, and there were no specific guidelines."

The board's decision came in response to a request by Dr. Fernando Colon, a board-certified plastic surgeon and associate medical director of the Skin Center Medical Spa in Gahanna.

Colon argued that allowing nurses to do the procedure would enable him and his colleagues to serve patients more effectively and efficiently.

"A well-trained nurse can continue to repeat this treatment, while I'm at the office doing other things," he said. "In a well-supervised environment, I think it is safe for a nurse to administer these Botox injections."

Colon's request, submitted last year, sparked months of discussion, much of it focusing on potential complications.

"What happens in a bad outcome?" board member Eric Yoon, a nurse practitioner from Springboro, asked at one hearing. "Just call 911?"

Ultimately, the board agreed with Colon but said nurses first must complete a "preceptorship," a period of practical experience and training supervised by a physician, Emrich said.

The board also determined that Botox can't be administered in homes, beauty salons or shopping malls, she said.

Still, some Ohio physicians aren't happy with the decision.

Dr. Michael Sullivan, a board-certified plastic surgeon in Columbus and former director of facial, plastic and reconstructive surgery at the Ohio State University Medical Center, had testified that Botox injections should be left to experienced plastic surgeons or dermatologists.

In unqualified hands, Sullivan said, the drug can cause a number of problems, including muscle weakness, drooping and bruising.

"We're going to hear of more and more complications and potentially deaths, because more and more physicians want to get out of insurance medicine and look at Botox and fillers and some of these quick procedures as a way to create a lucrative practice," he said.

In February, the U.S. Food and Drug Administration reported that Botox had been linked "to adverse reactions, including respiratory failure and death, following treatment of a variety of conditions using a wide range of doses." The most serious side effects stemmed from the "off-label" use of Botox to treat limb spasms in children with cerebral palsy, the agency said.

Last month, more than a dozen people filed a lawsuit against Allergan in California, where the company is headquartered. The plaintiffs contend that Botox injured them or killed their relatives and that Allergan failed to warn them of potential dangers.

Allergan said Botox has been used safely by millions of people.

Ohio Nurses call for change in prescription drug law

See this article

http://www.crainscleveland.com/article/20070702/FREE/70628013

Here is the cut and paste:

It’s 2:30 a.m. You’re an advanced practice nurse on staff at an acute care facility somewhere in Ohio. One of your patients wakes up, crying out with pain.

Your instinct, naturally, is to alleviate that pain. But it’s Sunday morning, and the 24-hour Percocet prescription you prescribed for the patient on Friday just expired, and state law forbids a refill.

At this point, the only way you can give her the medicine is to get approval from the patient’s physician.

Some say that’s exactly how it should be, and Ohio law backs up that sentiment. Others — including thousands of nurses — believe it’s time for a change.

Leading the latter cause is Jacalyn Golden, who works for the department of advanced practice nursing at the Cleveland Clinic.

As chairwoman of the legislative committee of the Ohio Association of Advanced Practice Nurses, she’s spearheading an effort to make Ohio the 32nd state in which advanced practice nurses (APNs) have the ability to prescribe Percocet and other highly controlled substances, without going through a doctor. APNs are registered nurses who have received post-graduate education to give advanced clinical care.

Currently, APNs are allowed to prescribe such drugs, but with limitations: only in 24-hour increments and with approval from the physician who initiated the medication.

The arrangement, Ms. Golden said, is “kind of ridiculous. … People who work up in intensive care, (seeing patients) with severe pain … they have to interrupt the surgeons to be able to prescribe, even though it’s well within their training.”

The Ohio State Medical Association, a membership organization advocating on behalf of physicians, is the Ohio Association of Advanced Practice Nurses’ primary opponent.

They argue that nurses, even APNs, aren’t sufficiently trained to diagnose independently within Schedule II, the contentious class of drugs that includes potentially addictive pain relievers such as fentanyl and attention deficit disorder medications such as Ritalin. (There’s no argument over APNs prescribing less-risky drugs in Schedules III through V.)

“Having the authority to prescribe for those drugs should really be guarded,” said Tim Maglione, the state medical association’s senior director of government relations. To give APNs the authority would “blur the line between the practice of medicine and the profession of nursing.”

Mr. Maglione said there is particular concern over whether APNs could prescribe medication in retail clinics or pharmacies. As for the bill, Mr. Maglione says the association hopes to work with the nurses for a “compromise.”

Ms. Golden is devoted to promoting Ohio House Bill 253, which would remove the restrictions and make Schedule II prescriptions a collaborative process between the APN and an Ohio Board of Nursing prescriptive governance committee, composed of physicians, pharmacists and other nurses.

Contained within the bill is language empowering the nursing board’s committee to determine which Schedule II substances a qualified APN can prescribe and under what circumstances.

The Ohio bill, sponsored by Rep. Scott Oelslager, R-North Canton, is co-sponsored by several other representatives and has support from several major health care institutions around the state, including the Cleveland Clinic and University Hospitals Health System, Ms. Golden said.

The bill, introduced May 31, has been assigned to the health committee, according to the Ohio Legislative Service Commission. It will be taken up again in the fall. If approved, it would then go to the Ohio Senate.

Lisa Emrich, manager of education and practice at the Ohio Board of Nursing, said the proposed change is rather small. “(APNs) already have the ability to care for these types of patients within their own practices,” she said. “There’s already quite a bit of oversight.

Controlled Substance Administration, Documentation & Handling

If you are a nurse and you want to be investigated by the State Nursing Board or State Attorney General's office (in some states AG's office investigates complaints), this is one surefire way that will lead to an investigation.

Alot of my current cases involve the administration, documentation, handling, and wasting of controlled substances. Alot of the phone calls I receive from nurses seeking attorney representation involve the same.

Slow down, take your time, and document. You can't practice and document "willy nilly" with controlled substances. You just can't do it anymore. Why? Chemical dependency is an issue with healthcare workers. 2. Rise in drug diversion (using a drug in manner for which is was not intended) 3. Rise in Drug Theft with healthcare workers. If you are chemically dependent or impaired, you need to speak with someone.

When the shit hits the fan and it will, your employer (nursing management and human resources) will not support you. You most likely will be terminated ( 9 times out of 10), reported to the Nursing Board and/or Pharmacy Board (depending on the state), and law enforcement will be notified (depending on the state and circumstances involved).

I have worked exclusively with nursing licensure defense for 7 years and I have yet to receive a call from a nurse who remarks that his or her employer is "in my corner" in these cases. Actually, I find when employers attempt to counsel and advise nurses in these situations (you don't need to be an attorney to give a nurse advice anyway do you?) its wrong and based on inappropriate assumptions.  

PICC Line Verification in Ohio is the Practice of Medicine

See this memo from the Ohio Medical Board to the Ohio Nursing Board. http://www.nursing.ohio.gov/PDFS/NextMeeting/M2/5.4.6PICCVerification.pdf

Are nurses in your jurisdiction legally permitted to place and verify placement of PICC lines?

Recognizing an Learning Need and Acting Upon It

See http://wbjournal.com/j/index.php?option=com_content&task=view&id=3638&Itemid=139.

A very practical manual for nurses who work in cysto rooms and assist with urological procedures. It is entitled “Cysto Room Survival Manual: Guidelines for Urologic Endoscopy.” All the proceeds of the book go back to the Society of Urological and Associates. See http://www.suna.org/cgi-bin/WebObjects/SUNAMain

Is there a similiar manual available in your practice area? Should a manual be available in your practice area? What about a pocket size manual for nurses in your organization? For your specific unit on the most common patient populations and medication given?

Primary Nursing with the Nursing Shortage: Is it still possible?

See this editorial appearing in ADVANCE for Nurses.

http://nursing.advanceweb.com/editorial/content/editorial.aspx?prg=3&cc=110560.

Is primary nursing still possible in today's healthcare system? According to the editorial:

"Her primary nurses on each unit identified themselves as the persons responsible for her care, discussed goals, informed her of what to expect and prepared her for transfer to another unit or for discharge."

My nephew was admitted to Cincinnati Children's Hospital Medical Center in December and my grandmother was hospitalized at University Hospital in Cincinnati. I spent most of December 2007 in Hospital rooms and clinics and I didn't observe any form of primary care nursing. What I observed was survival staffing and the band-aid approach to nursing care.

Which is one of the reasons why anytime my nephew who has an ASD and Pulmonary Hypertension is hospitalized, someone (me, my mother, one of my sisters, or a grandparent) is ALWAYS present at the Hospital. 

What are your experiences with primary care nursing? Is primary care nursing a reality on your unit? Did you observe primary care nursing when your family, friend, or loved one is hospitalized?