respond5

one page per peer, one reference per page.

PEER ONE

Alexija Romanovic

Hello all! June 1st and we are officially heading into summer! How exciting:) 

This was an interesting scenario to imagine myself in, as I have been employed in a medical position under a FNP before; so imaging myself in the position of an NP especially with a mistake such as the one described is thought provoking. Although the medical assistant likely believed she was helping a patient, prescribing a medication without provider authorization places the patient, healthcare provider, and organization at substantial risk.

Part A: 

• At the micro-level, the primary concern to safety. The patient received an antibiotic without a proper assessment by a licensed provider, which bypasses the clinical decision making  process necessary to determine whether antibiotics were actually necessary to begin with. I actually recall, as an MA, many patients coming in with colds asking for antibiotics, but once the provider assessed them found antibiotics inappropriate for their infections. As we know, taking antibiotics when unnecessary  could result in adverse medication reactions, delayed diagnosis of a more serious condition, or unnecessary antibiotic exposure that contributes to antimicrobial resistance. Ethical principles of beneficence and nonmaleficence were violated because treatment was provided without appropriate clinical evaluation. Legally, the medical assistant acted outside her scope of practice, and the unauthorized use of the NP’s name creates potential liability for both the provider and the practice.
• At the meso, or organizational level, the healthcare system shares responsibility for ensuring safe and legally compliant practices. This incident suggests potential gaps in oversight, prescription authorization processes, or enforcement of scope-of-practice policies. If unauthorized prescribing occurred without detection, the practice and larger hospital system could face regulatory scrutiny and legal liability. Healthcare organizations are responsible for maintaining clear documentation, supervision procedures, and role boundaries for all staff members (Office for Civil Rights, 2023). Ethically, leaders must ensure policies are clearly communicated and consistently enforced to promote accountability, patient safety, and compliance with professional standards.
• At the macro-level, this event intersects with broader public health concerns. Inappropriate antibiotic prescribing is a well-documented driver of antimicrobial resistance, which the World Health Organization identifies as one of the greatest global health threats (WHO, 2023). Research examining outpatient antibiotic prescribing patterns found substantial opportunities for antimicrobial stewardship interventions to reduce unnecessary antibiotic use and improve prescribing practices (Staub et al., 2020). When unqualified individuals prescribe antibiotics without proper clinical assessment, it undermines these stewardship efforts and may contribute to poor patient outcomes

Part B: 

• To prevent this happening in the future, the practice should implement a clear, written, policy should be established (or reinforced) that explicitly prohibits medical assistants from initiating, authorizing, or communicating prescription approvals to patients or pharmacies without direct, documented provider instruction. Among other preventions, I would suggest to do regular prescription audits, and provide regular education regarding scope-of-practice limitations.
• Addressing this situation with the medical assistant requires a careful balance of accountability and professionalism. Given her 10 years of experience and strong rapport with patients and providers, it is important to approach this conversation with both seriousness and respect, avoiding a purely punitive tone that could undermine psychological safety in the workplace. I would use the Situation-Behavior-Impact (SBI) feedback model. This approach allows the issue to be addressed objectively while emphasizing the impact on patient safety, legal compliance, and organizational integrity. Open-ended questions can help identify contributing factors while reinforcing accountability and expectations for future practice. The feedback conversation should also be documented in writing, clearly outlining the specific policy violation, the potential consequences for both the provider and the organization, and the behavioral expectations going forward.

Part C: 

• I found the Plan-Do-Study Act (PDSA) to be the most appropriate model for addressing this situation because it is evidence-driven, focusing on continuous quality improvement and process evaluation in clinical practice settings (Institute for Healthcare Improvement, 2023). Unlike Lewin’s three-step model, which addresses broader cultural change, or Kotter’s eight-step model, which is designed for large-scale organizational transformation, PDSA allows the practice to test a focused intervention on a small scale before full implementation.
  • Plan: Identify the problem (which was unauthorized prescription generation), define the goal (obviously, zero unauthorized prescriptions), and develop the intervention,  a real-time provider authorization protocol with an EHR audit trail.
  • Do: Implement the protocol on a trial basis within one provider’s patient panel or across one week of prescription renewals.
  • Study: Auditing the results: figuring out whether all prescriptions were properly authorized and if there were any workflow disruptions? What was staff responses? Etc.
  • Act: Based on findings, refine the protocol and roll it out practice-wide, with ongoing monitoring embedded in the process.

PDSA is particularly valuable because it acknowledges that change in complex healthcare environments rarely goes perfectly on the first attempt and builds in a structured mechanism for learning and adaptation (Institute for Healthcare Improvement, 2023).

Part D: 

• The biggest barrier, I believe, to implementing any change is staff resistance, particularly from the medical assistant in question who has been in the practice for a decade. Long-tenured employees sometimes develop informal workarounds that feel efficient to them, even when those practices violate policy. She may perceive new oversight measures as a reflection of distrust rather than a patient safety improvement. Overcoming this barrier requires transparent communication about the rationale for change and inclusion of staff in the design of new workflows where appropriate.
• As for the key facilitator of change, I believe, for this situation, top down change is necessary–that being the larger hospital system. With a larger system, the practice naturally gets more access to compliance officers, legal counsel, human resources professionals, and quality improvement teams who can support the implementation of new policies and auditing processes. Moreover, electronic health record safeguards can help ensure successful implementation and sustainability of the change process. Additionally, strong nurse leadership and a culture of patient safety can facilitate staff engagement and acceptance of change initiatives (Haskins et al., 2022).

This was an interesting scenario and I’m looking forward to everyone else’s interpretations! 

References: 

Haskins, H. E. M., & Roets, L. (2022). Nurse leadership: Sustaining a culture of safety.Health SA = SA Gesondheid,27(1), 2009–8. https://doi.org/10.4102/hsag.v27i0.2009

Institute for Healthcare Improvement. (2023). Plan-Do-Study-Act (PDSA) worksheet. https://www.ihi.org/resources/tools/plan-do-study-act-pdsa-worksheet

Office for Civil Rights. (2023). Summary of the HIPAA Privacy Rule. U.S. Department of Health and Human Services. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html

Staub, M. B., Ouedraogo, Y., Evans, C. D., Katz, S. E., Talley, P. P., Kainer, M. A., & Nelson, G. E. (2020). Analysis of a high-prescribing state’s 2016 outpatient antibiotic prescriptions: Implications for outpatient antimicrobial stewardship interventions. Infection Control & Hospital Epidemiology, 41(2), 1–8. https://doi.org/10.1017/ice.2019.315Links to an external site.

World Health Organization. (2023). Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance

PEER TWO

AA

Ama Bright Amudoaghan

May 31 10:58pm

Ethical and Legal Implications (Micro-, Meso-, and Macro-Level)

At the micro-level, this situation raises ethical and legal issues related to patient safety, provider accountability, and the scope of practice. The medical assistant (MA) independently facilitated an antibiotic prescription under the nurse practitioner’s (NP’s) name without evaluation or authorization. This violates the principles of nonmaleficence and beneficence, as inappropriate prescribing can cause adverse reactions, resistance, and missed diagnoses.

At the meso-level, the incident shows system failures in workflow, communication, and policy enforcement. The lack of safeguards that enable an MA to prescribe indicates weak internal controls. This risks liability, regulatory breaches, and accreditation issues.

At the macro-level, this issue affects healthcare policy, antimicrobial stewardship, and regulation. Unauthorized antibiotic prescribing undermines efforts against resistance and breaches standards by regulatory bodies.

Recommended Changes:

• Implement strict prescription authorization protocols that require direct provider approval.
• Restrict EMR access to ensure that only licensed providers can generate prescriptions.
• Develop clear role delineation policies outlining tasks that are outside MA scope.
• Introduce regular chart reviews to monitor prescribing practices.

Coaching and Feedback Strategy:A private but direct conversation should occur using a coaching framework grounded in accountability and professional development. The NP should:

• Begin with objective facts.
• Explore understanding.
• Reinforce expectations.
• Link to patient safety: Emphasize risk to the patient and the team.

Change Model Selection: Lewin’s Theory of Planned Change

Lewin’s Theory of Planned Change is the most appropriate model for this situation because of its structured approach to behavioral and systems change.

• Unfreezing:Recognize the unsafe practice and create awareness among staff regarding the risks and policy violations. This includes openly discussing the incident (without assigning blame) and highlighting legal and patient safety concerns.
• Movement (Change):Implement new protocols, including EMR restrictions, prescription verification processes, and staff education. Provide training and reinforce appropriate workflows.
• Refreezing:Sustain the change by integrating policies into daily practice, conducting audits, and reinforcing expectations through leadership oversight and ongoing feedback.

Barrier and Facilitator to Change

Barrier:A key barrier is the experienced MA’s perceived autonomy and informal power within the practice. Long-standing staff often develop strong relationships and influence, which may lead to resistance when new restrictions are introduced.

Facilitator:A major facilitator is the presence of organizational structure and leadership authority within a larger hospital system. Established policies, access to compliance resources, and leadership support can promote successful implementation of change.

                                                                                                    References (APA Style)

Kaini, B. K., & Kaini, B. K. (2020). Power dynamics in healthcare systems.

Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.

Topp, S. M., Schaaf, M., Sriram, V., et al. (2021). Power analysis in health policy and systems research. BMJ Global Health, 6(2), e004268.

Gottlieb, L. N., Gottlieb, B., & Shamian, J. (2021). Strengths-based nursing leadership.

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