This section will review various scope of practice issues since this case involved a nurse not questioning a doctor's orders that went against established practice and threatened patient safety. The discussion is not meant to be definitive or all inclusive.
- Basic concepts
- Blood transfusion and scope of practice
- Can physician orders ever be disobeyed?
- Responsibilities of health professionals
- This case
- Self study questions
- Further Reading
Before getting to the crux of of this case (if it is ever appropriate to disobey physician orders), some basic background information on scope of practice and inter-professional collaboration will be presented to help put the main issue in perspective.
Scope of Practice
In brief, scope of practice can be defined as the activities that a profession can or cannot do as defined by law. The purpose of legalized scopes of practice is to ensure that individuals involved in patient care have the required education, training, and professional qualifications.
Usually when health professionals discuss scope of practice, they refer to practitioners with different education and qualifications within the same field, e.g., medical laboratory technologists/scientists vis-à-vis laboratory assistants; RNs vis-à-vis LPNs, etc.
Increasingly in an age of health reform and financial restraints, the discussion on scope of practice may be inter-professional, e.g., nurse practitioners vis-à-vis physicians or pharmacists vis-à-vis physicians. See, for example:
- Alberta pharmacists earn right to prescribe drugs
- Patient's choice: Doctor or nurse practitioner?
- National standards urged for nurse practitioners
In reality, due to to the unavailability of physicians in remote locations, medical technologists and nurses may sometimes find themselves making decisions that in larger centres would normally be made by physicians. Scope of practice may vary slightly and unofficially (under the radar) with location depending on ready access to physicians.
See this discussion: Scope of nursing practice - a review of issues and trends by the CNA (1993 but still informative - includes information on international nursing)
Ideally, health providers work collaboratively to provide quality patient care. Collaborative care (CMAJ 1996;154: 21-7)is a concept that has been around for awhile and has grown in importance. Collaborative practice can be defined as patient-centred care involving at least two caregivers from different disciplines working together with the patient to meet assessed health care needs.
- See Interprofessional collaboration (CNA position statement)
Blood Transfusion and Scope of Practice
With blood transfusion the physician has sole responsibility for prescribing transfusions and is the one responsible for specifying dosage. Standards and regulations specify the role of physicians in the transfusion process. Canada's guidelines are similar to those of other countries:
CSTM Standards (Z902-04 references as superscripts)
L1.2 Transfusion of blood and blood products shall be prescribed by a physician. 11.4.3 The physician's order should specify:
- L1.2.1 Patient's first and last name and unique identifier number
- L1.2.2 The amount and type of blood, blood products and other related products to be transfused
- L1.2.3 The date, time and duration of the transfusion
- L1.2.4The sequence in which multiple products are to be transfused
- L1.2.5 Any modification to the product i.e. irradiation, washing
- L1.2.6 Special transfusion requirements i.e. Anti-CMV neg products, irradiation etc.
- L1.2.7 Clinical indication for transfusion
- L1.2.8 The use of a blood warmer or rapid infusion device, with the exception of clinical areas where there is an established hospital policy and procedure
- L1.2.9 Pre/post transfusion medication orders related to the transfusion
L1.3 The rate of infusion should be specified by the physician. 11.4.4
Of course, as with quality assurance (we are all responsible for it), all those who participate in the transfusion process are responsible for ensuring patient safety by performing work within their scopes of practice to acceptable standards.
Can Physician Orders Ever Be Disobeyed?
The crux of this case is whether disobeying physician orders is ever warranted, and if so, under what circumstances. The question can more properly be framed as whether questioning physician orders is ever warranted. Of course, the word order suggests a command given by a superior military officer that is meant to be obeyed.
Many, if not most, transfusion orders will lack some of the items required by blood safety standards. If minimal information regarding dose, rate, pre- and post-medication, and vital sign orders are not included, questionning the doctor's orders really amounts to clarifying the orders. Such clarification is incumbent upon care givers before proceeding with the transfusion and is common practice with respect to medication orders and pharmacy. Thus, clarifying transfusion orders can be considered analogous to clarifying drug orders, a well established norm.
Although questioning a physician's orders is certainly not the norm, the short answer is yes - a doctor's orders can be questioned and disobeyed if they contravene established best practices and standards and jeopardise patient safety. The collaborative approach, however, would be to discuss the issue with the physician so that questionable treatment orders would be revised and, therefore, not need to be disobeyed.
Depending on the institution's degree of collaborative practice and the corresponding inter-professional culture, it may be advisable politically to have another physician discuss the issue with the patient's doctor (peer-to-peer). Politics and pecking orders are not important - patient safety is - and achieving that is paramount.
The physician responsible for the TS is likely in the best position to consult with the ordering physician to revise orders. TS/blood bank policies may be helpful since the blood bank may have guidelines or requirements that must be met before blood products can be transfused. If an order seems unusual with respect to product or dose, a nurse may first wish to ask the blood bank staff about the order - and the blood bank staff may be able to have their TS physician intervene or consult.
These issues are discussed in more detail below.
Examples - Laboratory Technologist / Scientist
The main circumstance in which laboratory technologists may sometimes question physician orders is when a transfusion request appears unusual with respect to quantity or product type, e.g., if a physician orders:
- 2 RBC for a patient scheduled for a hysterectomy and the maximum surgical blood order schedule specifies a type and screen
- 2 RBC for a post-surgical, non-bleeding female patient with a hemoglobin of 95 g/L
- 6 platelet concentrate for a patient undergoing splenectomy
- 6 platelet concentrate for a non-bleeding patient with a platelet count of 110 X 109/L
- 6 platelet concentrate for a patient with thrombocytopenic purpura (TTP)
- 6 cryoprecipitate for a patient with von Willebrand's disease
Inappropriate orders may be wasteful of scarce resources but have neutral effects on safety; but more likely they pose a real or potential risk to patient safety. Transfusion itself must be justifiable and physicians must carefully assess the need for each blood order and weigh the benefits and risks.
Sometimes seemingly inappropriate physician orders are medically valid but this is determined only by questioning and consultative follow-up by a qualified expert such as the transfusion service medical director to assess the patient's entire clinical picture.
For a consultative approach to be feasible, a transfusion service must have appropriate staffing levels; experienced, knowledgeable staff; in-house guidelines for filling transfusion requests (e.g., platelet counts required for platelet orders); access to guidelines on the clinical uses of blood products, such as Clinical Guide to Transfusion (CBS, 2006); and a readily accessible medical director or consultant with transfusion medicine expertise.
Examples - Nursing
Because they provide direct patient care, nurses and physicians have close collaborative roles. Transfusion-related circumstance in which nurses may question physician orders include issues related to blood administration, e.g.,
- an order to infuse Ringer's lactate into the same line as red cells being transfused
- an order to transfuse blood over longer than 4 hours
- an order to transfuse non-irradiated RBC for a patient at risk for graft-vs-host disease, e.g., on purine analogues
- standing orders to transfuse, if the patient's condition changes
Nurses also have a role to play in helping to establish facility-wide "standardized" orders for transfusion. These are pre-printed doctors "orders" related to transfusion that have agreed-upon vital sign frequency, accompanying infusion solutions (normal saline and not Ringers) and "blanks" for the particular number of units of blood products and the particular rate of transfusion appropriate for the product and the patient. They may also have check boxes for special attributes such as irradiation or CMV-negative products. Use of such standardized orders helps to ensure that requirements of blood safety standards are not missed when orders are written.
Again, seemingly inappropriate physician orders may be medically valid but this is determined by questioning and follow-up consultation.
Responsibilities of Health Professionals
Nurses and other health professionals do not fulfill their responsibilities by obediently carrying out the orders of the treating physician regardless of patient consequences:
Nurses and allied health care professionals have a duty to question physician orders that are inappropriate or unclear. If they do not ask such questions, and a patient is harmed as a result of an inappropriate order, the nurse or allied health professional is just as liable for damages as the physician. (Malpractice. In: Gale Encyclopedia of Nursing and Allied Health)
Although the following principles apply to nurses, they apply to other health professionals too:
North Carolina courts have held that nurses "may disobey the instructions of a physician where those instructions are obviously wrong and will result in harm to the patient." The nurse is not permitted to abandon his/her judgment even if the physician promises to take liability. (Perlow D, Perlow M. Courts' perceptions of the responsibilities of nursing practice Kentucky Nurse 2005 Oct-Dec.)
Therefore, not only is it acceptable to question physician orders that appear to contravene best practices and standards and put patient safety at risk, it is the responsibility of health providers to do so. This duty to question applies to all inter-professional team work. As discussed in Courts' perceptions of the responsibilities of nursing practice, nurses and other health practitioners have primary duties to their patients and employers (e.g., hospitals).
Joint responsibility for patient safety does not mean that health providers such as nurses and technologists should be held to more accountability for errors than the physicians whose scope of practice is responsible for any decisions taken and who should be as aware of policies and procedures as the "front line" staff who may be in the firing line when errors are made.
This Case (Scope of Practice -Best Practice Issues)
The first issue in this case is that the patient's physician appeared to be unaware of current standards on transfusion time limits.
- The transfusion service medical director spoke to the patient's physician about blood safety guidelines and standards and provided relevant resources such as the CBS Clinical Guide to Transfusion (2006).
- As well, the medical director brought the standards issue up at the next meeting of the regional blood transfusion committee, using the incident as an educational tool.
The second issue is that the nurse transfused a unit of red cells over 8 hours, well beyond the usual 4 hour time limit specified in blood safety standards:
- CSTM L4.1 Administration of red cells should be completed within four hours of the time of issue from a temperature-controlled environment. (Z902-04 #11.4.6)
Note that the Standard says should, not shall. If a longer than usual transfusion time is anticipated for medical reasons, many facilities recommend that a blood bank physician be consulted. See these discussions on the CBBS e-Network forum:
- Transfusions that exceed four hours
- Clarification of the maximum time allowed for infusion of blood components
The purpose of both the "four hour rule" and "30-minute rule"* is to decrease the risk of bacterial growth in blood kept at room temperature. These limits are conservative and, like many blood bank guidelines, not necessarily evidence-based. However, blood is out of controlled refrigerators on many occasions prior to transfusion, e.g., during component preparation, when being packed for transportation to hospitals, when samples are taken for pretransfusion testing, when sent to the ward but not used, etc. Conservative limits are prudent when patient safety is involved.
* CSTM K6.2 Blood shall not be returned to inventory or reissued if they have been at room temperature or in an uncontrolled environment for longer than 30 minutes.10.10.4/11.4.7
A possible remedy for a slow running transfusion would be to find a new IV access, but in this case it was impossible because the patient had poor vein access and would have required a new port-o-cath insertion or a central venous access, not considered possible as the patient was already unstable.
When transfusions are to be infused so slowly that they would run more than 4 hours, an alternative is to split the unit of RBC into two smaller bags using a sterile connection device. The remainder of the unit is good for the entire shelf-life of the unit as though it were unaltered.
If sterile connection devices are unavailable, alternatives include:
Splitting a unit of RBC in the laboratory (without an SCD) and holding it for 24 hours at refrigerator temperature. The lab can split a full unit, issue half for transfusion over 4 hours and keep the other half in the fridge, to be issued for transfusion to the same patient any time within the next 24 hours - again - to be infused over 4 hours once issued.
Ordering pediatric packs from blood supplier
Stopping the transfusion after 4 hours and hanging a new donor bag (as a last resort)
Issue #3A related issue is that the nurse followed a physician's order that contravened normal practice without directly questioning the order and explaining that it went against best practice standards. Specifically, the nurse followed the physician's order "to continue transfusion even if it takes all day" and transfused the unit over 8 hours.
Upon questioning, the nurse said:
- She knew about the "4-hour rule" but was unsure of its rationale.
- She thought that by contacting the physician about the slow running transfusion she had, in effect, questioned him. The physician then made a decision and she followed it.
- She did not think that she had the authority to question the physician's order further since doctors, not nurses, were responsible for ordering transfusions and specifying their rates of infusion.
- As well, she had graduated two years ago and until now had worked in a setting where physicians were seldom, if ever, questioned.
Not questioning orders that compromised patient safety was seen as a systemic problem:
- The incident was used to refresh not only the nurse in question but all clinical staff on the standards/policies related to blood administration.
- The nurse's unit manager made a point of ensuring that the nurse was not "centred out" for special remediation.
As well, the case emphasized the need for all physicians to receive continuing education to ensure their familiarity with current guidelines for transfusion and knowledge of policies and procedures in their own institution.
TS consultative role. The TS and blood supplier have important roles to play in making clinicians aware of current transfusion guidelines and standards and providing consultation. Within a hospital or health region, the TS can also help educate clinical staff on specific issues.
For example, if blood infusion over greater than 4 hours can be identified (e.g., by audit and review of occurrences tracked over time) then the TS may have a role in educating other healthcare providers about the rationale for this rule and in providing reminders. The following is an example of a reminder:
- After consultation with nurse educators on the unit, the TS included a pink sticker on the tags from nursing units that tended to exceed the 4-hour transfusion limit that said: This blood product must be completely infused within 4 hours of issue from the blood bank. The transfusion end time is:________.
- Upon receipt, the receiving nurse would fill in the blank regarding transfusion end time - making sure that it was less than 4 hours hence.
These issues are discussed further in Part 4 (Education to function as part of interdisciplinary healthcare teams).
- Scopes of practice ensure that health professionals have the required education, training, and professional qualifications.
- Within their respective scopes of practice, members of the health care team collaborate in providing patient care.
- Nurses and allied health care professionals such as medical laboratory technologists have a duty to question physician orders that are inappropriate or unclear, even if the responsibility is outside their scope of practice.
- When orienting new nurses, it is useful to discuss inter-professional issues such as when and how to question physician orders and when physicians need to be contacted. The same applies to the transfusion service laboratory, which typically has these policies built into its SOPs.
TraQ Self Study Questions
What could the nurse in this case have done when the physician gave orders to transfuse the slow running unit even if it took all day?
Under what circumstances can physician orders be questioned?
How does scope of practice relate to questioning the actions of other health professionals?
- Part 1: Administering blood products
- Part 2: Investigating adverse events
- Part 3: Scope of practice issues<--You are here
- Part 4: Education for interdisciplinary healthcare teams
Scope of practice
- Alberta pharmacists earn right to prescribe drugs
- Patient's choice: Doctor or nurse practitioner?
- National standards urged for nurse practitioners
- Scope of nursing practice - a review of issues and trends
Collaborative team work
- Collaborative care receives stamp of approval in CMA, CNA study involving HIV/AIDS (CMAJ 1996;154: 21-7)
- Interprofessional collaboration (CNA position statement)
- CBBS e-Network forum
- CBS. Clinical Guide to Transfusion (2006)
- CSTM. Standards for Hospital Transfusion Services, v 2
- Malpractice. In: Gale Encyclopedia of Nursing and Allied Health
- Perlow D, Perlow M. Courts' perceptions of the responsibilities of nursing practice