Advanced practice nursing update: Prescription labeling issues

Advanced practice nursing update: Prescription labeling issues

Recently, the ANA transmitted a letterto the National Council for Prescrtption Drug Programs to initiate dialogue on prescription labeling practices. Simultaneously, ANA contacted various advanced practice groups, including the American College of Nurse Practitioners (ACNP) and informed them of efforts to address prescription labe ling practices. The ACNP, a longtime advocate for nurse practitioners, has initiated similar efforts and is collecting data from its members to provide ANA with an empirical base to address this issue. The entire letter sent to the National Council for Prescription Drug Programs is available from KSNA, but excerpts are printed below.

Excerpts Only

March 10, 2000

Lee Ann Stember, President

National Council for Prescription Drug Programs 4201 N. 24th Street 23365 Phoenix, AZ 85016-6268

Dear Ms. Stember:

The American Nurses Association is the only full-service professional organization representing the nation’s 2.6 million Registered Nurses through its 53 constituent associations.

As the Executive Director of ANA, I am writing to you because our organization also represents advanced nurses who prescribe. These nurses have expressed concerns about the prescription labeling process. Advanced practice registered nurses (APRNs) are nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists who have some form of prescriptive authority in fortynine states.

Although states authorized nurse prescriptive practice in the mid 1970’s, APRNs continue to have problems getting prescriptions filled. Advanced practice registered nurses continue to inform us that pharmacists refuse to include their names and numbers on prescriptions because the pharmacy software was not constructed to address APRN prescribing. APRN licensure numbers are not constructed in a manner consistent with your standards. And, even in the states where it has been structured in this manner, nurses still have problems with pharmacists’ acceptance of prescriptions because the label isn’t structured to incorporate the APRN’s name and title. In more than twenty states, APRNs have controlled substance prescriptive authority and pharmacists continue to require the names and DEA numbers of physicians because the software makes reference to “Dr.” In those few instances in which a nurse’s name is listed on the prescription, the nurse is referred to as “Dr.” Over the years, staff and representatives from ANA have met with various pharmaceutical organizations and associations and in every instance, your organizational standards have been cited as the foundation for our concerns. It was our hope that this matter would have been resolved over time. However, with the resurgence of new complaints, we feel compelled to direct our concerns to you.

In light of the recent Institute of Medicine report on medication errors, the failure of the label to identify the actual prescribes creates considerable legal problems. As well as safety concerns for the person taking the drug, nurses may legally prescribe independently, with a collaborating physician, or with indirect or direct supervision of their practice. Each permutation of prescriptive authority carries a different level of liability for the associate working with the nurse. When an APRN practices independently and encounters this type of problem, s/he typically has to enter into a relationship with a physician to facilitate her practice. In remote areas, an NP is often the only health care provider available. While the APRN is independently accountable for patients and prescribing practices, the physician associate who signs off on the prescription or allows use of the assigned DEA number creates the appearance of physician supervision and intervention further creates liability if the nurse’s prescribing is deficient or negligent. Likewise, the APRN who is required to work in a collaborative relationship under state law also may have prescriptions attributed to the prescribing physicians when state law does not necessarily require physician co-signature on the prescription. The APRN is placed in the position of misrepresenting the individual who prescribed the drug, not because it is the nurse’s intent to do so, but because the software does not lend itself to the accurate listing of the prescribes. Those who work in supervised relationships where cosignature may be necessary are also misrepresenting their practice. The labeling software does not allow for the listing of both physician and APRN. In some states, APRNs have fought to obtain DEA numbers, not because they prescribe controlled substances, but because the number is needed to get prescriptions filled. Even though the DEA frowns on this practice, APRNs have felt frustrated by pharmacy software that cannot be modified to identify and properly label prescriptions. These pharmacies need to have the ability to recognize the NP’s prescriptive authority in order to avoid imposing another system-based obstacle to the delivery of quality health care services.

The problem also leads to the development of inaccurate data about physician practice. As the labeling system is presently structured, more prescriptions are attributed to the physician than he writes when workingwith an NP. Thus, the pharmaceutical company gets an inaccurate portrait of prescribing patterns. Likewise, state drug utilization review programs may inappropriately target physicians who are assisting APRNs by signing off on their prescriptions. The prescribing pattern may be inconsistent with state DUR requirements thus triggering an investigation. I’m sure these implications were not anticipated and that your organization might wish to review your standards to address these concerns.

Please find enclosed information on APRN nurse prescription practices foryour review and to initiate dialogue. ANA is committed to providing staff to better inform you about this issue as well as working with you to seek a resolution. This problem is of concern to all parties and ANA is committed to work with the National Council for Prescription Drug Programs. . .

Again, I look forward our building a constructive dialogue and seeking resolutions to these concerns. Sincerely,

David W. Hennage, PhD, MI Executive Director

K.SA.40-2250. Insurance coverage to include reimbursement for services performed by advanced registered nurse practitioners. (a) Notwithstanding any provision of an individual or group policy or contract for health and accident insurance delivered within the state, whenever such policy or contract shall provide for reimbursement for any services within the lawful scope of practice of an advanced registered nurse practitioner within the state of Kansas, the insured, or any other person covered by the policy or contract, shall be allowed and entitled to reimbursement for such service irrespective of whether it was provided or performed by a duly licensed physician or an advanced registered nurse practitioner.

History: L. 1990, ch. 162, 3; L. 1993, ch. 137, 1; July 1.

ARNP Name Not On The Prescription Bottle Yet?

KSNA staff have prepared a sample letter for ARNP’s to use to send to local pharmacists who may not be clear about the fact that scheduled drug orders by ARNP’s when filled must include the name of the ARNP on the prescription label. Our sincere desire is that pharmacists will place the ARNP’s name on all prescriptions for all the same reasons stated in the letter from ANA to the National Council for Prescription Drug Programs.

If you’d like a copy of the sample letter KSNA staff can mail, fax or email it to you to use. KSNA785.233.8638 or

Copyright Kansas State Nurses Association Jun/Jul 2000

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