When Can Nurses Dispense Medications?

Question
Our emergency department (ED) is equipped with automated dispensing cabinets that store medications for use in the ED, including prescription medications (eg, a course of antibiotics). I know that physician dispensing is acceptable in the absence of a pharmacist, but some nurses are concerned that they are "dispensing" or practicing outside of the nursing practice act if they hand the patient the prescription bottle. Is this an acceptable practice for nurses, assuming that the physician controls the process, that there are safety processes in place (ie, double-checks), and that medications are labeled properly?

Response from Bonnie L. Senst, MS, RPh, FASHP Clinical Assistant Professor, University of Minnesota College of Pharmacy, Minneapolis, Minnesota; Director, Allina Pharmacy Practice, Allina Hospitals and Clinics, Minneapolis, Minnesota

The question of nurse dispensing authority arises in various prescription scenarios:

1. Handing out a prescription or sample medication authorized by the physician (as in the question above)

2. Transcribing prescription information from chart orders to prescription blanks

3. Transcribing information onto a prescription blank as part of a verbal or telephone order from a physician

4. Verbally transmitting prescription information (written by the physician in the chart or on a prescription blank) to a retail pharmacy

5. Using a clinic refill protocol to authorize a prescription refill (eg, a protocol that specifies nursing assessment involved, authorized medications, refill criteria)

Because medical, nurse, and pharmacy practice acts vary from state to state, the first step would be to check the applicable state regulations and nursing practice act. The second step would be to check the hospital bylaws and policies for any language regarding delegation of authority to nurses. Often hospital policies specify transcribing or verbal order authority, but usually they do not specify details regarding prescriptions. Without any specific state statute or nursing practice act language addressing prescription issues, these questions often require interpretation of other existing regulations.

For illustration purposes, let's look at some of the statutes and nurse practice act language that would be used in evaluating a similar scenario in Minnesota. There, dispensing prescriptions is under the authority of physicians and specified advanced practice registered nurses who are authorized to prescribe drugs; this authority includes dispensing of drug samples.^[1] Taken at face value, this could be interpreted to mean that other nurses cannot dispense.

However, 2 other regulatory statements could be used in the interpretation:

Agent of the physician. According to the Minnesota Nursing Practice Act, the practice of professional nursing "includes both independent nursing functions and delegated medical functions which may be performed in collaboration with other health team members."^[2] There are many functions in the hospital or clinic that are delegated to nurses, pharmacists, and other individuals as an agent of the physician. Tasks such as receiving telephone and verbal prescription orders, transcribing, and transmitting prescription orders and providing discharge medication instructions are activities often performed by nurses. If there is no language to exclude prescriptions, then some may interpret that prescriptions can be included and would consider the first 4 scenarios above to fall within this scope.

Specific authority under protocol. The Minnesota statutes specify that "a registered nurse may implement a protocol that does not reference a specific patient and results in a prescription of a legend drug that has been predetermined and delegated by a licensed practitioner" (with designated conditions).^[3] Without specific regulatory language such as this, interpretation of the refill scenario may vary.

When evaluating regulatory and scope-of-practice issues, state nursing and pharmacy practice boards can assist in identifying language that authorizes or limits practices. As noted in the question, appropriate physician involvement and quality procedures should always be in place to support safe practices.

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Cite this: When Can Nurses Dispense Medications? - Medscape - Mar 12, 2009.