Taking cross-training too far

November 4, 2005

Most states prohibit individuals from calling themselves a nurse unless they have the required credentials.

Q. I'm a family physician in a large, well-established group practice. When I started here, all of our nurses were either RNs or LPNs. As they've left or retired, however, their jobs have often been filled by medical assistants.

Recently, when one of our RNs retired, she was replaced by our former front desk receptionist, who has no medical training. After a short crash course, she's being introduced to patients as a "nurse," and is now giving injections, dressing wounds, and authorizing some medication refills.

I'm concerned about the ethical and legal implications of this situation, and about my own liability if something goes wrong when she's "treating" one of my patients.

Patients can be misled even when a practice doesn't intentionally misrepresent its clinical staff. More commonly, a practice may simply neglect to clearly identify a staffer's professional status, leading patients to assume the person is more qualified than she actually is. Each clinical staffer's status should be clearly and accurately identified.

Physicians who permit unqualified or unlicensed persons to diagnose or treat patients or dispense medication are exposing themselves to a serious liability risk. If one of your patients is injured by someone who's not permitted by law to administer treatment or medication, a malpractice suit against you and your group could be both indefensible and costly. Such a case could result in punitive damages based on allegations of fraud and misrepresentation. In fact, some insurers might refuse to provide coverage for the claim, and it's unlikely that your former receptionist-turned-"nurse"'s on-the-job training would impress a jury.

Your group should ask your state medical and nursing boards about current regulations and laws governing these medical personnel issues. For example, it may be illegal for an untrained, unlicensed, or uncertified individual to inject a patient with any substance, or to provide some of those other services you describe.

If your practice employs medical assistants or other clinical assistants, it should develop training and supervision programs that comply with state laws and regulations, which typically limit the type of services a nurse or PA can provide to patients. The group should make sure that all its midlevel professionals function within clear, written guidelines, and that their performance is periodically monitored and documented.

I advise your group to get legal advice on this issue. You should also ask your malpractice insurer if your policy covers patient care services provided by unlicensed staff. I suspect it doesn't, and the carrier probably won't be happy to learn about it.

The author is a risk management and loss prevention consultant in Cloverdale, CA. He can be reached by e-mail at lossprevention@earthlink.net
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This department answers common professional liability questions. It isn't intended to provide specific legal advice. If you have a question, please submit it to Malpractice Consult, Medical Economics, 5 Paragon Drive, Montvale, NJ 07645-1742. You may also fax your question to 973-847-5390 or e-mail it to memalp@advanstar.com
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