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Mini case studies

Scenario 1

Selena is new to rural nursing practice. For the last three months she’s been working at a small community hospital. Tonight, she is working in the Emergency d​epartment.

While Selena is reviewing her​ client’s lab results at the nursing station, she hears footsteps. She looks up to see a man who hands her a paper and says, “My doctor sent me to get this filled.” Selena sees it’s a prescription from a local physician.

Selena asks him to take a seat and tells him she needs to assess him. He says that he doesn’t have time for that, “I’ve already seen my doctor. Can’t you just give me t​he pills so I can go?”

Selena considers her options. She knows t​he hospital has the medication in stock. There isn’t a pharmacist on site, but she knows nurses can dispense medications to clients with a physician’s/NP’s client-specific order. 

What should Selena do?

Dispense the medication

That’s not correct. If Selena dispenses the medication, she would not be meeting the Medications Practice Standard. While she has an order for the medication, the man is not her client. Without knowing anything about him, she’s not able to determine if the order is appropriate for him.

What are potential consequences of dispensing to someone who is not your client?

  • Inability to check pharmaceutical and therapeutic suitability of the medication for the client
  • Cannot document dispensing as there is no client record
  • Cannot obtain the best possible medication history and review the client’s PharmaNet profile and medical record
  • Unable to review allergies or past adverse reactions, contraindications, therapeutic duplications or potential drug interactions, alcohol or drug use and other health issues
Not dispense the medication

Correct. Selena doesn’t dispense the medication because the man is not her client, and she can’t determine whether the medication ordered is appropriate. Selena lets the man know he must either be assessed or take the prescription to a pharmacy to be filled.

Nurses dispense medications only for clients under their care and when it is in the best interest of the client. When nurses dispense medications, without a pharmacist’s involvement, they need to ensure its proper use, and the pharmaceutical and therapeutic suitability. Before dispensing, nurses:

  • Review the order for completeness and appropriateness (e.g., dosage, route, frequency)
  • Review the client’s medication history and other health information
  • Consider potential drug interactions, allergies, contraindications (e.g., adverse side effects)

The Medication Practice Standard provides nurses with the information to dispense medications safely.

Scenario 2

You are working in a small community hospital. One of your clients has been discharged with a prescription for antibiotics. The local pharmacy is closed. The unit has a stock of this medication.

What should you do?

After ensuring pharmaceutical and therapeutic suitability, dispense the medication following organizational policy.

Correct. Nurses can dispense medications to a client under their care when it is in the client’s best interest, the medication has been ordered by an authorized health professional, and where organizational policy allows.

Do not dispense the medication because there is no pharmacist on site.

That’s not correct. Under the Regulations, nurses can dispense a medication when a pharmacist is not available if the medication has been ordered by an authorized health professional and where organizational policy allows.

Dispense the medication even though you are not familiar with its use.

That’s not correct. Sometimes it may be more appropriate for another nurse or a physician to dispense the medication. If you think you are not the most appropriate person to dispense the medication, consult the health professional who gave the medication order to determine the best course of action.


Scenario 3

During the morning medication administration round, you notice a new medication on a client’s MAR that you are unfamiliar with.

What do you do?

Do not administer it because you are not familiar with it. Leave the new medication for the next shift.

That’s not correct. Nurses adhere to the ‘rights’ and checks of medication administration: Right medication, Right client, Right dose, Right time, Right route, Right reason and Right documentation. Nurses understand how medication errors and near misses can occur and take steps to prevent them.Refer to the Medication Practice Standard.

Consult with the charge nurse before giving the medication then look up the medication in an organization-recognized drug guide following the completion of the morning medication administration round.

That's not correct. Nurses determine all orders for a client are clear, complete, current, legible and appropriate for the client before administering any medication. (See the Medication Practice Standard).

Look up the new medication in an organization-recognized drug guide before administering it. If you still have concerns, discuss the medication with the dispensing pharmacist.

Correct! Nurses are responsible for administering medications and adhering to the ‘rights’ and checks of medication administration: Right medication, Right client, Right dose, Right time, Right route, Right reason and Right documentation. (See the Medication Practice Standard).

Administer the new medication. After administration, call the pharmacist to discuss possible interactions with current medications.

That’s not correct. Before administering any medication, nurses are knowledgeable about the effects, side effects and interactions and take action as necessary. Refer to the Medication Practice Standard.

Workplace policies may place restrictions on medication administration over and above that of the nursing Regulations and BCCNM standards, limits and conditions. Organizations are responsible for providing the supports and systems necessary for safe medication administration by nurses, including medication reconciliation and reporting of medication incidents and near misses​. ​​​​​​​​​

 Scenario 4

​​​ ​I have a client who was recently admitted ​to the unit. Their admission assessments and associated document​​ation has been completed but the primary healthcare provider won't be in for another couple of hours to write medication orders. The client is complaining of moderate pain due to a headache. Can I treat this client's pain within my autonomous scope of practice (i.e., give pain medication without an order)? 

​​What do I need to consider?

The controls on practice and the Medication practice standard can guide you in your decision-making. Your first step is to determine whether this is an activity you are:

  • Authorized to perform as outlined in the nursing regulation relevant to your designation
  • Determine if there are standards, limits, and conditions you need to meet associated with the activity
  • Allowed to perform in your workplace
  • Competent to perform within your autonomous scope of practice​

Start by thinking about the activity and the controls on practice by asking these questions:

Does the legislation allow/restrict me from carrying out this activity?

According to the Nurses Regulation, nurses are authorized to: administer/dispense Schedule II & III medications and a limited number of Schedule I medications within their autonomous scope of practice. 

Does BCCNM allow/restrict me from carrying out this activity?

BCCNM's standards, limits and conditions outline the requirements you need to meet when acting within autonomous scope of practice. Nurses are authorized to act within their autonomous scope of practice if they meet the principles outlined in applicable standards. 

Does my organization allow/restrict me from carrying out this activity?

Check relevant policies and protocols at your workplace for carrying out a medication-related activity without a client-specific order. Specifically, does the organization allow it? What policies need to be followed when carrying out the activity? Can you meet all these requirements? 

Does my individual competence allow/restrict me from carrying out the activity?

Evaluate your individual competence in carrying out the activity. Do you have the required knowledge, skills and abilities to do so safely? 

If you determine that you are authorized to carry out the activity, review the Medication practice standard to see what additional requirements you need to meet related to medication-related activities and acting within your autonomous scope of practice. Remember, when acting within autonomous scope of practice nurses are the most accountable and responsible provider when administering or dispensing a medication wit​​hout an order. Being the sole decision-maker increases risks to the client.

Additional Medicat​ion practice standard requirements:​

  1. Following organizational policies and processes
  2. Assessing the client's health status including allergies
  3. Making or confirming a nursing diagnosis of a condition that can be improved or resolved by administering or dispensing a medication.
  4. Deciding if the client would benefit from the medication, considering known risks and benefits, factors specific to the client or situation, and medication alternatives
  5. Managing monitoring and evaluating the client's response to the medication (as applicable) including intended and unintended outcomes. 
  6. Communicating and collaborating with the client (or their substitute decision-maker) and the health care team and document the nursing diagnosis, decision, actions, and outcomes related to the medication administered or dispensed to the client.

The Acting within Autonomous Scope of Practice thinking tool can help you.​​

Decision​​

After reviewing the controls on practice, the Acting within Autonomous Scope of Practice standard and the Medication practice standard, you determine that you are authorized and competent to treat your client's condition within your autonomous scope of practice.

Following your workplace's protocol for autonomously treating mild to moderate pain, and consulting your client about their wishes, you administer pain medication and document your care in the client's medical record. You communicate your intervention to the client's care team.

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With great respect, we acknowledge that BCCNM’s office is located on the unceded territories of the hən̓q̓əmin̓əm̓ speaking peoples – xʷməθkʷəy̓əm (Musqueam), and sel̓íl̓witulh (Tsleil-Waututh) Nations, and the Sḵwx̱wú7mesh-ulh Sníchim speaking peoples - Sḵwx̱wú7mesh Úxwumixw (Squamish Nation) whose historical relationships with the land continue to this day.​