InfoLAW: RN Prescribing

Please note: In this document, “dispensing of medication” specifically refers to RNs dispensing medication in the absence of a medical order for the treatment of a specific condition(s) following the RN’s nursing assessment.

In an effort to safely improve timely access to care for certain patient populations, an increasing number of Canadian provinces and territories have legislated (or are in the process of legislating) the ability for a Registered Nurse (RN) to prescribe or dispense certain medications autonomously under the RN scope of practice. This expanded scope of practice usually involves assessing, diagnosing and treating certain limited medical conditions by dispensing or prescribing medications. The practice is limited to RNs who work in specialized areas of practice or who work in a setting where additional adequate support is available from clinical support tools, and physicians or nurse practitioners.

Qualifications

Currently, RN prescribing requires formal authorization from the nursing regulator in the form of a certification or an advanced designation. This formal authorization to prescribe is based on successful completion of approved specialized education and/or practice experience. RNs authorized to incorporate prescribing in their practice will also be expected to fulfill all continuing education or competency requirements.

Regulatory framework and support for the practice of RN prescribing

RN prescribing is authorized within specific parameters, related to the patient’s medical condition and its complexity, practice setting, patient population, choice of medication and ability to order screening or diagnostic tests. These parameters are set out in regulations, standards of practice or practice directions, and/or other forms of clinical support documents (clinical or decision support tools, protocols, guidelines, explanatory guides). Clinical support documents may also generally list the indications and contraindications of contemplated treatments, set out specific appropriate pharmacological interventions (including the specific medication, dosage, frequency, etc.), identify potential complications and follow-up, and indicate when to consult a physician or Nurse Practitioner.

Courts and disciplinary committees are likely to refer to these documents to determine if an RN met the appropriate standard of care (what a reasonable and prudent nurse would have done in similar circumstances), and complied with their professional obligations when prescribing or dispensing medication using their own authority.

RNs with additional authority to prescribe or dispense should carefully review and understand the governing regulations, standards, practice directions, and any other document intended to serve as a clinical support tool to know what content:

• is mandatory;
• is intended as a guideline (i.e. a description of how the RN is expected to proceed in most cases but which can, using professional knowledge and judgment, be adapted to the specific circumstances of the patient), and
• is to be used as a clinical reference (i.e. useful information that the nurse would already be expected to know and rely upon to make decisions about patient care).

Understanding and respecting the limits of the advanced authorization to prescribe or dispense medication will reduce the risk of a claim that the RN is practising outside the permitted scope of practice, and the legal risks that this could entail. For example, there could be disciplinary action by their regulatory body and/or their employer, as well as a charge of unauthorized practice of medicine or Nurse Practitioner practice.

Clinical and legal considerations associated with prescribing medication

Although the prescription of medication is expected to assist in resolving or controlling a medical condition, it can have known or unexpected side effects for the patients. Adverse consequences have also been known to result from the wrong choice of medication, the inappropriate dosage, the medication’s interaction with other medications, or the failure to follow up on the medication’s effectiveness and continued appropriateness, amongst other things.

Standards, practice directions and other clinical support assist in reducing these risks by setting out practice expectations such as:

1. Making adequate inquiries, completing a thorough examination, taking a proper history as well as ordering laboratory or diagnostic imaging tests to identify the pathology that requires treatment and to establish if medications are indicated;
2. Establishing that the medication is not contraindicated for the particular patient;
3. Establishing the appropriate dosage, mode and frequency of administration;
4. Obtaining the patient’s informed consent and instructing the patient about the administration of medication;
5. Monitoring the effectiveness of the medication and identifying any potential complications.

Please note that as of December 2019, health facilities are required to report serious adverse drug reactions and medical device incidents to Health Canada.¹ This procedure helps identify potential safety issues and improve health product safety for all Canadians by identifying previously unrecognized adverse reactions and communicating the new reactions with healthcare facilities.²

The following clinical and legal considerations may also assist in reducing potential risks:

a) Are you making full use of your own professional knowledge, skill and judgment?

Although the standards, practice directions and other practice support tools developed by nursing regulators generally provide a comprehensive framework and guide for the practice of RN prescribing, it is not possible to anticipate every possible scenario or patient presentation. RNs should continually apply their professional judgment to assess whether a proposed course of treatment is appropriate in the circumstances. Here are a few guidelines to keep in mind:

• Is the patient’s presentation also indicative of other medical conditions? Have they been ruled out?
• Have you conducted a medication reconciliation? Is the patient taking other medications that should be taken into account? Have you assessed whether the patient is taking any natural health products that should be taken into account?
• Does the patient suffer from other pathologies or conditions that should be taken into account in arriving at a diagnosis or in the choice of treatment?
• Does the treatment of the patient fall outside your knowledge, skill and judgment?

b) Have new standards, guidelines or medication alerts been published that should be taken into account?

Clinical knowledge is constantly evolving, and the treatment of a medical condition may need to be informed by newly revised guidelines or standards from sources recognized as authoritative in the healthcare community. Manufacturers or government authorities may also advise of newly uncovered contraindications for certain medications. Are there means by which this information is brought to your attention to determine the preferred course of treatment? Would that preferred course of treatment still fall within the range of treatments permitted by the regulator? If not, should a consultation be arranged with a Nurse Practitioner or physician to implement a course of treatment that meets the standard of care?

c) Are there other professional obligations, employer policies or ethical considerations that should be considered?

Other standards, guidelines, employer policies or ethical considerations may apply. For instance, an employer policy may restrict the circumstances in which their employee RN prescriber may exercise that authority. A conflict of interest acts as an example of an ethical consideration. RN prescribers should be familiar with policies and guidelines on conflicts of interest and the extent to which they may preclude treatment of family members and friends.

d) Does the patient have the necessary capacity to provide an informed consent and implement the treatment?

Informed consent is defined as a person receiving “the information about the treatment that a reasonable person in the same circumstances would require to make a decision.”³ Consider whether consent must be obtained from a substitute decision-maker⁴ and whether the patient has adequate support at home to ensure that the patient will take the medication as prescribed.⁵

e) During your assessment, have you identified an unrelated condition needing follow-up care of which the patient seemed unaware?

It is well-accepted that a health-care professional, to meet the standard of care, is not required to investigate conditions unrelated to the reason for the patient’s consultation. However, if, in the course of conducting an assessment, a health-care professional noted an unusual presentation or made a finding that could be indicative of a serious health condition, a court would be likely to find that the health-care professional had an obligation to alert the patient to this condition or take other reasonable steps so that an appropriate follow-up could be arranged.

f) Has the patient been provided with adequate discharge instructions?

Canadian courts have held that patients who are returning home to implement a course of treatment should receive adequate information for self-care. This would normally include:

• the diagnosis;
• instructions on how to implement the course of treatment and anything to avoid;
• the duration and expected outcome of the treatment;
• information about planned follow-up, if any;
• the potential complications of the treatment, their implications, signs and symptoms, what to do if they should occur, and when to seek medical attention.⁶

g) Are the prescription pads kept out of the reach of others?

Prescription pads or similar materials should be stored in a secure location to reduce the risk of loss or theft.

h) Have your interactions with the patient been adequately documented?

It would be prudent to specifically include steps taken to rule out contraindications for treatment, significant risks mentioned during the discussion about informed consent as well as a summary of discharge instructions to the patient. Handouts, customized for patient needs as necessary, are an appropriate way of documenting the discussion and assisting the patient with self-care. They can also serve as a helpful legal risk-management tool if a copy is retained in the chart.⁷

Professional liability protection for RN prescribers

RNs with additional authority to prescribe or dispense medication, who are beneficiaries of the CNPS,⁸ continue to have access to the full range of professional liability protection and legal services of the CNPS, provided their professional practice remains within the boundaries of their authorized scope of practice.

CNPS beneficiaries can contact CNPS at 1-800-267-3390 to speak with a member of CNPS legal counsel. All calls are confidential.

1. Health Canada, Report a side effect, online: https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/adverse-reaction-reporting.html. 2019.
2. Ibid.
3. College of Nurses of Ontario, Practice Guideline: Consent, online: http://www.cno.org/globalassets/docs/policy/41020_consent.pdf, Feb 2017.
4. The CNO defines this as a person identified by the Health Care Consent Act who may make a treatment decision for someone who is incapable of making his/her own decision (http://www.cno.org/globalassets/docs/policy/41020_consent.pdf).
5. For more information, please consult CNPS’ InfoLAW on Consent to Treatment: The role of the nurse:https://cnps.ca/article/consent-to-treatment/.
6. Georghiades v MacLeod, 2005 CanLII 14149 (ON SC)
7. See Fowlow v Gupta, 2012 ONSC 6531 (CanLII), in which the court stated, “Despite [the nurse’s] lack of express recollection of the events in question, [the patient’s] signature on the document is strong confirmation that he received the document and the instructions that [the nurse] says were her standard practice. […] In the circumstances, I prefer and accept [the nurse’s] version of what took place when [the patient] was discharged.”
8. To confirm whether you are a CNPS beneficiary, visit https://cnps.ca/services/eligible/.

Published in 2018, updated in October 2020.

THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.