Title: Verification of Orders

Advisory Ruling Number: 9324 (formally Verification of Medication Orders)

Authority: The Massachusetts Board of Registration in Nursing issues this Advisory Ruling on Nursing practice pursuant to Massachusetts General Laws, chapter 30A, section 8 and chapter 112, section 80B.

Date Issued: September 22, 1993

Date Revised: July 10, 2002; December 9, 2009

Scope of Practice: Registered Nurse and Licensed Practical Nurse

Purpose: To guide the practice of Registered Nurses and Licensed Practical Nurses when receiving patient care orders from a duly authorized prescriber pursuant to Massachusetts General Laws, chapter 112, section 80B.

Advisory: It is the responsibility of the licensed nurse to ensure that there is a proper patient care order from a duly authorized prescriber prior to the administration of any prescription or non-prescription medication in accordance with accepted standards of practice and in compliance with the Board's regulations.

Such practice must be in compliance with Massachusetts General Laws (G.L.) c. 112, s. 80B; 244 CMR 3.02: Responsibilities and Functions - Registered Nurse; 244 CMR 3.04: Responsibilities and Functions - Practical Nurse; 244 CMR 9.03(5): Adherence to the Standards of Nursing Practice; 244 CMR 9.03(9): Responsibility and Accountability; 244 CMR 9.03(38): Administration of Drugs; 244 CMR 9.03(44); Documentation; and 244 CMR 9.03(46): Responsibilities of Nurse in Management Role; and M.G.L.Chapter 94C: Section 17: Necessity of prescription for dispensing controlled substances and Section 20: Oral prescriptions.

Nurse's Responsibility and Accountability

Licensed nurses receive, transcribe and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal, telephone, standing, pre-printed, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. The paramount importance of patient safety must be reflected in protocols that are specific to the setting and circumstance. Determination of individual client/resident/patient allergy must be included in each protocol. The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse's knowledge of that particular patient's care needs at that time and must also ensure that the orders (whether verbal, electronic, written, or standing orders) originate from an authorized prescriber.

Medication Orders

Minimum required elements: The minimum elements required for inclusion in a complete medication order include:

  • Patient/client/resident/student's full name
  • Name of the medication
  • Dose and route of the medication
  • Frequency of the medication administration
  • A valid medication order date
  • Specific directions for administration
  • Signature of the duly authorized prescriber
  • Signature of the individual accepting/verifying the order

Pharmacy labeled container

In certain and limited situations, it is within the licensed nurse's discretion to accept an original pharmacy labeled container in lieu of an order from a duly authorized prescriber. Situations include, but are not limited to:

  • Schools
  • Adult & Pediatric day care
  • Summer camp
  • Other nursing care settings

When choosing to accept an original pharmacy labeled container in lieu of an order from a duly authorized prescriber, the licensed nurse must consider the following:

  • The setting must have a policy and/or procedure guiding/directing this activity.
  • The medication container must be intact with a completely written and legible label.
  • The medication expiration date can not be exceeded.
  • When indicated, there must be parental or guardian consent.
  • The label must contain all the perquisite information necessary prior to administrating a medication (i.e. The 5 Rights).
  • Determination of individual client/resident/patient allergy must be done.
  • The nurse is accountable for ensuring that any orders he or she implements are reasonable based on the nurse's knowledge of the patient's care needs and that the orders originate from an authorized prescriber.

Role of the Nurse in a Management Role

The licensed nurse in a management role must develop and implement the necessary measures to promote the delivery of safe nursing care in accordance with accepted standards of care, such as those issued from time to time by The Joint Commission (TJC) and The Institute for Safe Medication Practices (ISMP).

Such measures must include and define at a minimum:

  • acceptable methods of order communication within the practice setting
  • circumstances in which the method can be used
  • competency in accepting orders required for each method
  • specific safety measures that must be employed to ensure patient safety:
    • telephone and other verbal orders must include read-back policies
    • timeframes for authentication can not exceed state or federal requirements
    • abbreviation policies
    • any limitation on verbal orders for specific medications that may be considered unsafe to prescribe in non-written format

References

  • Department of Health and Human Services; Centers for Medicate and Medicaid Services, 42 CFR Part 482. Federal Register: November 27, 2006 (Volume 71, Number 227).
  • Federal Register: November 27, 2006 (Volume 71, Number 227), p. 29 of 47, accessed from World Wide Web, 7/29/09.
  • Center for Medicaid and State Operations/Survey and Certification Group: Ref: S&C-07-13 (Revised 2/23/07) Memorandum.
  • CMS tag A-1007: 482.23(c)(2)(ii)
  • Center for Medicaid and State Operations/Survey and Certification Group: Ref: S&C-09-10 Memorandum October 24, 2008
  • The Joint Commission; History Tracking Report: 2009 to 2008 Requirements, p. 2, © The Joint Commission 2008.
  • Joint Commission revised standard RC.02.03.07, 3/23/09
  • The Institute for Safe Medication Practices (ISMP) is a nonprofit healthcare agency comprised of pharmacists, nurses, and physicians. Founded in 1994, the organization is dedicated to learning about medication errors, understanding their system-based causes, and disseminating practical recommendations that can help healthcare providers, consumers, and the pharmaceutical industry prevent errors. www.ismp.org
  • National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body comprising 23 national organizations that works to maximize the safe use of medications and increase awareness of medication errors through open communication, increased reporting and promotion of medication error prevention strategies. www.nccmerp.org
  • Timothy S. Lesar, PharmD, Director of Pharmacy, Albany Medical Center. Produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Editorial Board and Advisory Panel. Accessed from the World Wide Web on 8/3/09 http://www.webmm.ahrq.gov/case.aspx?caseID=36, November, 2003.
  • http://www.ismp.org /newsletters/acutecare/articles/20010124.asp, from the 1/24/2001 issue. Accessed from the World Wide Web 8/4/09
  • http://www.nccmerp.org/council/council2001-02-20.html Accessed from the World Wide Web 8/4/09
  • Wakefield, D S, et al. Quality and Safety in Health Care 2009;18:165-168; doi:10.1136/qshc.2009.034041

This information is provided by the Division of Health Professions Licensure within the Department of Public Health.