Public Duties of the Healthcare Professional
After completing this chapter, you will be able to:
· 1. Define the key terms.
· 2. Describe the public duties of a physician.
· 3. Discuss the guidelines that should be used when completing a legal record or certificate.
· 4. List the information that must be included in a death certificate.
· 5. Describe the cases in which a coroner or health official would have to sign a death certificate.
· 6. List 10 reportable communicable diseases.
· 7. Discuss the Child Abuse Prevention and Treatment Act of 1974.
· 8. Describe eight signs that indicate a child, spouse, or elderly person may be abused.
· 9. Discuss the federal legislation of controlled substances.
· 10. List and explain the five schedules of drugs.
· 11. Explain how an Employee Assistance Program (EAP) can help troubled employees.
Bureau of Narcotics and Dangerous Drugs (BNDD)
Controlled Substances Act of 1970
Drug Enforcement Administration (DEA)
Employee Assistance Program (EAP)
Food and Drug Administration (FDA)
Material Safety Data Sheet (MSDS)
Restraining or protective order
THE CASE OF BRIAN B. AND THE MEDICAL FILE
Brian B. is taken into an exam room in the office of Dr. K. by the medical assistant, Amy. Amy gets into an animated discussion with Brian about their mutually favorite baseball team. As Amy leaves the exam room she accidentally places Brian’s medical file on the counter. While Brian waits for Dr. K., he reads through his file folder. He is shocked to discover that his recent test for AIDS came back positive. Brian panics and runs out of the office before seeing Dr. K. The doctor tries to reach Brian by phone but there is no answer. Dr. K. then sends a letter marked “Confidential” to Brian and explains that he must be treated for his disease and also needs to inform his sexual partners about his diagnosis. Brian does not respond to the letter.
· 1. What else can Dr. K. do to meet his obligation to report a communicable disease?
· 2. What responsibility does the medical assistant, Amy, have relating to this problem?
· 3. How might Brian be encouraged to report his condition to his sexual partners?
In order to protect the health of all citizens, each state has passed public health statutes that require certain information be reported to state and federal authorities. These statutes help protect the public from unsanitary conditions in public facilities such as restaurants and restrooms, and they require the examination of water supplies. Physicians and other healthcare workers must inform the government when a situation may affect public health, such as in the case of communicable diseases.
PUBLIC HEALTH RECORDS AND VITAL STATISTICS
Important events, or vital statistics , in a person’s life, such as birth and death dates, are used by the government, public health agencies, and other institutions to determine population trends and needs. The reporting agencies and services include the Department of Health and Human Services, Centers for Disease Control and Prevention, the National Center for Health Statistics, and the Public Health Service. The mortality rate , also called the death rate, is the ratio of the number of deaths to total population in a given location. The morbidity rate is the number of sick people or cases of disease in relationship to a specific population. The Mortality and Morbidity Weekly Report, a list of illness and death rates for a variety of illnesses, is published every week by the Centers for Disease Control (CDC) in Atlanta, Georgia. The CDC is always on the lookout for outbreaks of disease in major cities and all the states. Therefore, the CDC needs to have accurate input from physicians and healthcare officials of statistics relating to deaths and illness.
The physician’s duty to report these events is a duty owed the public— public duties . These duties include reports of births, stillbirths, and deaths; communicable illnesses or diseases; drug abuse; certain injuries, such as rape, gunshot, and knife wounds; animal bites; and abuse of children, spouses, and older adults. Additional information includes data such as marriages, divorces, and induced termination of pregnancies.
Office personnel such as nurses, medical assistants, and school nurses may carry out many of these reporting duties. The collection of this information should be taken seriously. The data —or facts, figures, and statistics—represent information about the individual patient’s life. In addition, some of the data are of a highly sensitive nature, such as the facts concerning rape, abuse, and death.
Even though office staff may actually perform the paperwork requirements of the law, the ultimate responsibility for reporting health statistics and abuse remains with the physician.
Recommendations for completing legal records such as birth and death certificates are summarized in Table 7.1 .
Physicians, primarily those assisting at births, issue the certificate of live birth that will be maintained during a person’s life as proof of age. A valid birth certificate is required to receive many government documents such as a Social Security card, passport, driver’s license, and voter registration.
TABLE 7.1 Recommendations for Completing Legal Records and Certificates
· 1. Request information from the state registrar for specific requirements on completing certificates.
· 2. Type all documents when possible. If the record is completed manually, then print using black ink.
· 3. Make sure that all blank spaces are completed.
· 4. Verify all names for correct spelling.
· 5. Use full original signature, not rubber stamps.
· 6. File original certificates or reports with the appropriate registrar. Copies or reproductions are not acceptable.
· 7. Avoid abbreviations.
· 8. Do not alter the certificate or make erasures.
· 9. Keep a copy in the patient’s file.
A physician must sign the certificate of live birth. For a hospital birth, the certificate is filed by the hospital at the county clerk’s office in the state in which the birth took place. If the delivery occurs at home, the midwife or person in attendance at the birth can file the birth certificate at the county public health department. While the time frame to submit a birth certificate varies somewhat from state to state, in most cases it must be done within the first week of the baby’s life. Some states impose a criminal penalty if the birth and death certificates are not properly completed and handled. If the birth has not been registered within a year, then the physician, midwife, or any other person in attendance at the birth may have to go to court to provide proof of the birth.
Physicians and others who attend a birth, such as midwives, are required to report certain diseases in newborns. Ophthalmia neonatorium is a serious eye condition present at birth that causes inflammation, swelling, redness, and an unnatural discharge in an infant’s eyes. If untreated, it may result in blindness. Evidence of this disease must be reported within 12 hours after birth. A test for the condition of phenylketonuria (PKU) is another test required by state health departments on newborns. PKU can be treated with dietary restrictions. In addition, some states also require testing for sickle cell anemia.
Some states impose a criminal penalty if a birth and death certificate are not handled correctly.
Physicians sign a certificate indicating the cause of a natural death. The Department of Public Health in each state provides the specific requirement for that state. For example, in the case of a stillbirth before the twentieth week of gestation, the physician must file both a birth and death certificate in some states. In other states, neither is required if the fetus has not reached the twentieth week of gestation. And in some states only a death certificate is required for a stillbirth after the twentieth week. In the case of a live birth with a subsequent death of the infant, both a birth certificate and a death certificate are necessary in all states.
The physician who had been attending the deceased person usually signs the death certificate, stating the time and cause of death. The physician must include the following information on the certificate:
· The date and time of death
· The cause of death: diseases, injuries, or complications
· How long the deceased person was treated for the disease or injury before dying
· The presence or absence of pregnancy (for female decedent)
· If an autopsy took place
In most states, a death certificate must be signed within 24 to 72 hours after the patient’s death. After the physician has signed the certificate, it is given to the mortician, who files it with the state or county clerk’s office.
Because funeral arrangements and burial cannot take place until the death certificate is signed, it is important that the physician sign as soon as possible.
The death certificate provides proof that a death has occurred. It is often required to confirm information concerning veteran’s benefits, Internal Revenue Service (IRS) information, insurance benefits, and other financial information when settling an estate. If a funeral home provides the burial, they will often obtain copies of the death certificate for the family to submit to agencies, such as the IRS. The death certificate must be signed as soon as possible after a person’s death. The time and date of the death are important facts and must be accurate.
In some deaths, a coroner or health official must sign a certificate. See Table 7.2 for a listing of cases that need a coroner’s signature.
TABLE 7.2 Cases Needing a Coroner’s Signature
· No physician present at the time of death
· A violent death, including homicide, suicide, or accident
· Death as a result of a criminal action
· An unlawful death such as assisted suicide
· Death from an undetermined cause (unexpected or unexplained)
· Death resulting from chemical, electrical, or radiation injury
· Death caused by criminal abortion, including self-induced
· Death occurring less than 24 hours after hospital admission
· No physician attending the patient within 36 hours preceding death
· Death occurring outside of a hospital or licensed healthcare facility
· Suspicious death, such as from a fall
· Death of a person whose body is not claimed by friends or relatives
· Death of a person whose identity is unknown
· Death of a child under the age of two years if the death is from an unknown cause or if it appears the death is from Sudden Infant Death Syndrome (SIDS)
· Death of a person in jail or prison
A coroner is the public health officer who holds an investigation, or inquest , if the death is from an unknown or violent cause. The coroner or medical examiner completes the death certificate if the deceased has not been under the care of a physician. In some states, the coroner will also investigate an accidental death, such as one resulting from a fall. A medical examiner is a physician, usually a pathologist, who can investigate an unexplained death and perform autopsies. An autopsy , which is a postmortem or after-death examination of the organs and tissues of the body, may have to be performed to determine the cause of death.
Unless the death results from suspicious causes, such as a homicide, an autopsy cannot be performed on a body without the consent of the surviving person who has the “first right” to the body. This person is usually a family member who is responsible for burying the deceased person.
Physicians must report all diseases that can be transmitted from one person to another and are considered a general threat to the public. The report can be made to the public health authorities by phone or mail. The communicable disease report should include the following:
· Name, address, age, and occupation of the patient
· Name of the disease or suspected disease
· Date of onset of the disease
· Name of the person issuing the report
The list of reportable diseases differs from state to state, but all states require reports of tuberculosis, rubeola, rubella, tetanus, diphtheria, cholera, poliomyelitis, acquired immunodeficiency syndrome (AIDS), meningococcal meningitis, and rheumatic fever. In addition, some diseases, such as influenza, need to be reported if there is a high incidence within a certain population. Sexually transmitted diseases (STDs) or venereal diseases, such as syphilis, gonorrhea, and genital warts, must also be reported to protect the public. Employees in food service, day care, and healthcare occupations are more carefully monitored for contagious diseases by public health departments.
A listing of childhood vaccines and toxoids that are required by law (the National Childhood Vaccine Injury Act of 1986) are found in Table 7.3 .
Many pediatricians also recommend that every child receive H. influenzae type b vaccine (HiB), hepatitis A vaccine, varicella (chicken pox) vaccine, and pneumococcal (pneumonia) vaccine (PCV7). In most states, newborn infants also receive erythromycin applied to both eyes and a Vitamin K injection to prevent hemorrhagic diseases of the newborn.
TABLE 7.3 Required Children’s Vaccines
· Diphtheria, pertussis (whooping cough), tetanus toxoid (DPT)
· Measles, mumps, rubella (MMR)
· Poliovirus vaccine, live
· Poliovirus vaccine, inactivated
· Hepatitis B vaccine (HBV)
· Tuberculosis test
The National Childhood Vaccine Injury Act, passed by Congress in 1986, requires a physician or healthcare administrator to report all vaccine administrations and adverse reactions to vaccines and toxoids. The physician must report information directly relating to the vaccine and toxoid, such as the manufacturer and lot number. In addition, the name and address of the person administering the vaccine and the date of administration should be documented in the patient’s record.
Duty to Report AIDS, HIV, and ARC Cases
All states have statutes or regulations that require healthcare providers to report cases of AIDS to the local or state department of health. Most states also require that human immunodeficiency virus (HIV) and AIDS-related complex (ARC) cases be reported as well. Who should report the cases varies. In some states, it is the duty of the attending physician or laboratory that performs the test. Other states may require hospitals, clinics, blood banks, and other facilities to report positive cases.
To date, Minnesota is the only state that has a self-reporting provision requiring healthcare workers who are diagnosed with HIV to report the fact to the health department or commissioner of health within 30 days of learning the diagnosis. In addition, the Minnesota law requires healthcare workers to report, within 10 days, of other healthcare workers who are infected (Minn. Stat., §214.18(2),(4).).
Many states have confidentiality statutes that allow notification of an HIV patient’s spouse, needle-sharing partner, or other contact person who is at risk of the infection (California Health and Safety Code 121015). A physician who wishes to notify a contact person under one of these laws should always discuss such plans with the patient first. The physician may wish to remind the patient of the moral obligation to others. Patients should always be informed that there are some statutes that impose criminal liability on someone who is an HIV carrier and knowingly engages in activities that could spread the virus to others (Fla. Stat. §Ann. 384.24.).
Disclosure to Patients of Health Workers’ HIV Status
Many people believe that healthcare workers have a moral obligation to disclose their own HIV-positive status to their patients. However, healthcare providers have argued that it is an unnecessary invasion of their privacy as there is little evidence that HIV is transmitted from healthcare providers to patients. The most notorious case occurred when a Florida dentist, who later died of AIDS, allegedly infected at least one of his patients. This patient later died of AIDS. The accused dentist practiced invasive procedures such as tooth extractions and fillings without practicing universal safety precautions such as wearing gloves and a mask. The allegations in this case have never been proven.
In 1985 a law went into effect that mandated the testing of all blood and tissue donors to protect any potential surgery and hemophiliac patients from the transmission of HIV. In addition, the requirement to use standard precautions was implemented. There are many people who believe that healthcare workers who practice any type of invasive procedures or techniques, such as injections and surgery, should be required to take an HIV test. The alternative is that healthcare workers should be tested if they have a needlestick incident. This HIV testing is currently done in hospitals whenever a needlestick incident occurs.
In spite of the lack of statistics to demonstrate that healthcare workers can infect their patients, patients still have a desire to know if they are at risk of being infected with HIV/AIDS. Because AIDS is a fatal disease, many patients believe they should be told if their physician is HIV-positive.
It is the duty of the physician to report communicable diseases, such as HIV, AIDS, and ARC. However, patients often feel more comfortable sharing personal information with nurses, physician assistants, medical assistants, or laboratory technicians. These healthcare professionals have a duty to report this information to the physician.
The first child protective agency in the world was established in 1874 when a little 10-year-old girl, Mary Ellen McCormack, explained to the court how her mother beat and abused her. The New York Society for the Prevention of Cruelty to Children began as a result of her story. She became known as “the child who put a face on abuse.”
The Child Abuse Prevention and Treatment Act of 1974 requires reporting of all child abuse cases. All states have statutes that define child abuse and require that all abuse must be reported. To begin to investigate questions of neglect and child abuse, the state must have probable cause , which is a reasonable belief that something improper has happened. Many states list personnel who are required by law to make an immediate report of any suspected child abuse. These personnel include teachers; health professionals such as physicians, emergency room staff, physician assistants, nurses, and medical assistants; law-enforcement personnel; daycare personnel; and social service workers. Questionable injuries of children, including bruises, fractured bones, and burns, must be reported to local law-enforcement agencies.
The term battered child syndrome is sometimes used by healthcare professionals to describe a series of injuries, including fractures, bruises, and burns, done to children by parents or caregivers. This is not a legal term but, rather, a description of injuries ( Figure 7.1 ). Signs of neglect such as malnutrition, poor growth, and lack of hygiene are reportable in some states. In a Minnesota case, the court ruled that the Minnesota Board of Psychology acted correctly when it revoked the license of a psychologist who failed to report the sexual abuse of a child (In re Schroeder, 415 N.W.2d 436, Minn. Ct. App. 1987).
Figure 7.1 A Young Child Explains her Injuries to a Physician
Physicians have been held liable if they do not report cases of child abuse. For example, in Landeros v. Flood, the state supreme court ruled that the physician should not have returned a battered child to the parents after he treated the child for intentionally inflicted injuries. The court held that the “battered child syndrome” was a legitimate medical diagnosis and the physician should have suspected that the parents would inflict further injury on the child (Landeros v. Flood, 551 P.2d 389, Cal. 1976).
Any person who suspects that child abuse is taking place can report the abuse to local authorities without fear of liability. It can sometimes be difficult to determine if a child’s injury is accidental or intentional. The persons reporting these cases, acting in the best interests of the child, are protected by law from being sued by parents and others. In the case of Satler v. Larsen, a pediatrician reported a case of possible child abuse concerning a four-month-old comatose infant to the Bureau of Child Welfare. There was not enough evidence to demonstrate that the parents were at fault, and they subsequently sued the physician for defamation. The defamation lawsuit was dismissed, because the physician reported the suspected abuse in good faith (Satler v. Larsen, 520 N.Y.S.2d 378, App. Div. 1987).
Most state statutes require that an oral report of suspected abuse be made immediately, followed by a written report. The written report should include:
· Name and address of the child
· Child’s age
· Person(s) responsible for the care of the child
· Description of the type and extent of the child’s injuries
· Identity of the abuser, if known
· Photographs, soiled clothing, or any other evidence that abuse has taken place
The person reporting a suspected case of child abuse is protected from civil and criminal liability unless that person is the abuser. However, failure to report a suspected case of child abuse may result in a charge of misdemeanor.
Parental neglect occurs when a parent or parents have a religious belief that does not allow medical treatment for their children. States refrain, as much as possible, from interfering with parental rights since the parents are the decision makers for their children. However, the state may have to step in when there is intentional neglect such as when a child is not receiving the medical care that could save his or her life. For example, members of some religious denominations do not allow blood transfusions. If a child suffers from leukemia, a type of cancer of the blood, he or she may need frequent blood transfusions in order to live. A full court hearing may be required to temporarily remove the child from the parent’s custody in order to obtain treatment. There have been cases in which parents were charged with murder, manslaughter, or negligent homicide when a child died due to apparent parental neglect.
Parents may have to be asked to leave the exam room while their child is questioned about suspicious bruises and injuries. See Child Abuse and Treatment Act in Chapter 12 .
Elder abuse is defined in the amendment to the Older Americans Act (1987). It includes physical abuse, neglect, exploitation, and abandonment of adults 60 years and older and is reportable in most states. The reporting agency varies by state but generally includes social service agencies, welfare departments, and nursing home personnel. As in the case of child abuse, the person reporting the abuse is, in most states, protected from civil and criminal liability.
Residents of nursing home facilities must be protected from abusive healthcare workers. To do so, some states have made “resident abuse” a crime. In the case of Brinson v. Axelrod, a nurse’s aide was prosecuted for resident abuse for causing injuries to the hands and face of an elderly resident (Brinson v. Axelrod, 499 N.Y.S.2d 24, App. Div. 1986). Another medical employee in a New York case was found guilty of resident abuse when she “held the patient’s chin and poured the medication down her throat” after the patient had refused medication (In re Axelrod, 560 N.Y.S.2d 573, App. Div. 1990).
The elderly are also protected by the Older Americans Act from financial abuse or exploitation. This is considered a crime in many states.
One of the most difficult situations that healthcare providers confront is when they suspect that a patient suffers from spousal abuse. Laws governing the reporting of spousal abuse vary from state to state. The local police may have to become involved when spousal abuse is suspected, and in some cases a court will issue a restraining or protective order prohibiting the abuser from coming into contact with the victim. Questions that are frequently asked of a suspected abused spouse include:
· Are you or your children afraid of your spouse?
· Does your partner threaten, grab, shove, or hit you?
· Does your partner prevent you from spending time with your family or friends?
· Do you stay with your partner because you are afraid of what he or she would do if you broke up?
· Has your partner ever abandoned you in a dangerous place?
Abused spouses are warned that in most relationships the cycle of abuse happens many times. The abuse does not stop.
All medical offices and hospital emergency rooms should have access to a 24-hour abuse hotline, such as a women’s support services hotline.
Signs of Abuse
Healthcare workers, social workers, daycare personnel, and nursing home staff should all be on the lookout for victims of abuse. However, physical signs in children, spouses, the elderly, and the mentally incompetent vary. These signs of abuse are found in Table 7.4 .
TABLE 7.4 Signs of Abuse
· Repeated injuries
· Bruises such as blackened eyes and unexplained swelling
· Unexplained fractures
· Bite marks
· Unusual marks, such as those occurring from a cigarette burn
· Bruising, swelling, or pain in the genital area
· Signs of inadequate nutrition, such as sunken eyes and weight loss
· Venereal disease and genital abrasions and infections
· Makeup used to hide bruises
· Sunglasses worn inside a building or hospital to hide blackened eyes
Healthcare workers must do everything possible to gain the victim’s confidence. However, it is not possible to assure the victim that all information will be held in confidence, as abuse cases are reportable by law. This should be clearly explained to the victim at the time of the initial visit.
It is difficult to discuss the abuse with the victim when the suspected abuser is present. Always attempt to speak to the victim in private. If possible, have another healthcare professional present during the interview to act as a witness.
Those persons who are unable to protect themselves, such as children and the elderly, must be protected by healthcare workers and caregivers who become aware of abusive situations.
Abuse of prescription drugs is reportable immediately, according to the law. Such abuse can be difficult to determine, as the abuser may seek prescriptions for the same drug from different physicians. A physician will want to see a patient before prescribing medication. A violation of controlled substances laws is a criminal offense. Prescription pads and blanks should always be kept locked up when not in use. Physicians will usually keep a pad in their pocket during working hours. Pads are never left out on exam room counters or desks.
All physicians and healthcare workers should be familiar with the laws relating to controlled substances. Violation of the laws can result in fines, imprisonment, and a loss of license to practice medicine.
Gathering Evidence in Cases of Abuse
Gathering evidence from abuse victims usually takes place in a hospital or emergency room setting. However, a physician may see an abused patient in the office. Precise documentation of all injuries, bruises, and suspicious fluid deposits in the genital areas of children is critical. The court may subpoena these records at a later date. The physician may also be asked to testify in court and offer observations.
Evidence in abuse cases includes the following:
· Photo of bruises and other signs of abuse
· Female child’s urine specimen (containing sperm) or laboratory report indicating the presence of sperm in the urine
· Body fluids, such as semen, vomitus, or gastric contents
· Various samples, such as blood, semen, and vaginal or rectal smears
· Foreign objects such as bullets, hair, and nail clippings
Evidence should be handled as little as possible, and by only one employee, to prevent damaging the evidence. All evidence in abuse cases should be clearly labeled and protected with sealed plastic bags or covers.
Chain of Custody for Evidence
It is important to maintain a clear chain of custody for evidence to verify that the specimen has been handled correctly. All evidence must be clearly labeled with the name of the patient, date, and time when the specimen was obtained, and all information regarding evidence should be carefully documented in the patient’s medical record. In addition to the time and date, the medical record should include complete documentation of the patient’s condition as well as the treatment that was provided. All photographs and x-rays should be carefully labeled with the patient’s name, patient registration number, time, and date. Items such as clothing, including underwear, must be retained as evidence and not handled excessively or washed. All evidence should be kept in a locked storage area until it is required.
Care must be taken when turning evidence over to a third party. Always request identification and authorization of the person as well as a receipt, which can then be placed into the medical record.
Other Reportable Conditions
Many states require physicians to file a report of certain medical conditions in order to maintain accurate public health statistics. These conditions include cancer, epilepsy, and congenital disorders such as phenylketonuria (PKU) of the newborn that can cause mental impairment if untreated. Because the testing for many of these conditions occurs in the hospital, the reporting responsibility rests on the hospital.
Gunshot wound laws require reports when injuries are inflicted by lethal weapons or by unlawful acts. In addition, every case of a bullet wound, powder burn, or any other injury arising from the discharge of a gun or firearm must be reported to the police authorities of the city or town where the person reporting is located. The report must be made by the physician treating the patient or an administrative person in charge of a hospital, sanitarium, or other institution.
Forensic medicine is that branch of medicine concerned with the law, especially criminal law, such as in gunshot cases resulting in death. A forensic pathologist is a physician who specializes in the examination of bodies when there are circumstances indicating that the death was unnatural, such as in suicide, accident, or homicide. Their examination usually includes an assessment of the time of death (from data such as the temperature of the corpse and decomposition), and a determination of the cause of death (based on a study of the injuries). They also examine blood, hair, and skin from the victim with those on any weapons, found in automobiles, or on the clothing of suspects.
Forensic pathologists also examine victims of sexual and child abuse. In addition, they consult in cases of attempted poisoning and drug abuse. They are called upon to advise on blood grouping in cases of disputed paternity.
CONTROLLED SUBSTANCES ACT AND REGULATIONS
The Food and Drug Administration (FDA) , an agency within the Department of Health and Human Services, ultimately enforces drug (prescription and over-the-counter) sales and distribution. The FDA came into existence with the passage of the Food, Drug, and Cosmetic Act of 1938, which sought to ensure the safety of those items sold within the United States.
Drugs that have a potential for addiction , an acquired physical or psychological dependence on a drug, habituation , the development of an emotional dependence on a drug due to repeated use, or abuse , misuse, excessive or improper use, are also regulated. The Drug Enforcement Administration (DEA) of the Department of Justice controls these drugs by enforcing the Comprehensive Drug Abuse Prevention and Control Act of 1970, more commonly known as the Controlled Substances Act of 1970 . This act regulates the manufacture and distribution of the drugs that can cause dependence and places controlled drugs into five categories that are called schedules: I, II, III, IV, and V. The Bureau of Narcotics and Dangerous Drugs (BNDD) is the agency of the federal government authorized to enforce drug control.
Physicians who administer controlled substances, also called narcotics, must register with the Drug Enforcement Administration (DEA) in Washington, DC, and the registration must be renewed every three years. A DEA registration number is assigned to each physician. A physician who leaves the practice of medicine must return the registration form and unused narcotic order forms to the nearest DEA office.
An accurate count of all narcotics must be kept in a record such as a narcotics log, and all narcotics records must be kept for two years. The date and the name of the person to whom the drug was administered, along with the signature of the person administering the drug, are recorded. In some states, physicians who prescribe narcotic drugs but do not administer them, such as dentists and psychiatrists, are also required to maintain narcotics logs and inventory records.
Most states limit the administration of narcotics to physicians and nurses. States may be more restrictive, but not less, than the federal government when regulating the administration of controlled substances. For example, a state may require physicians to keep controlled substances records for a longer period of time than the federal regulations require.
All narcotics must be kept under lock and key. According to the U.S. Food and Drug Administration, due to environmental concerns controlled (narcotic) drugs should only be “wasted” or destroyed down a toilet or drain, if there are specific instructions on the packaging to do this. Two people should be present when controlled substances are destroyed. Non-narcotic drugs should be removed from their original containers and properly disposed of with other medical waste.
The controlled drugs are classified into five schedules based on the potential for abuse, which are summarized in Table 7.5 .
TABLE 7.5 Schedule for Controlled Substances
Highest potential for addiction and abuse. Not accepted for medical use.
Cannot be prescribed.
May be used for research purposes. Example: marijuana, heroin, and LSD.
High potential for addiction and abuse. Accepted for medical use in the United States. Example: codeine, cocaine, morphine, opium, and secobarbital.
A DEA-licensed physician must complete the required triplicate prescription forms entirely in his or her own handwriting. The prescription must be filled within seven days, and it may not be refilled. In an emergency, the physician may order a limited amount of the drug by telephone. These drugs must be stored under lock and key if they are kept on the office premises. The law requires that the dispensing record of these drugs be kept on file for two years.
Moderate-to-low potential for addiction and abuse. Example: butabarbital, anabolic steroids, and APC with codeine.
A DEA number is not required to prescribe these drugs, but the physician must handwrite the order. Five refills are allowed during a six-month period, and this must be indicated on the prescription form. Only a physician may telephone the pharmacist for these drugs.
Lower potential for addiction and abuse than Schedule III drugs. Example: chloral hydrate, phenobarbitol, and diazepam.
The prescription must be signed by the physician. Five refills are allowed over a six-month period.
Low potential for addiction and abuse. Example: cough medications containing codeine, lomotil.
Inventory records must be maintained on these drugs.
A violation of the Controlled Substances Act is a criminal offense that can result in a fine, loss of license to practice medicine, and a jail sentence. Medical office personnel can assist the physician in maintaining compliance with the law by
· Alerting the physician to license renewal dates.
· Maintaining accurate inventory records.
· Keeping all controlled substances in a secure cabinet.
· Keeping prescription blanks and pads locked in a secure cabinet, office, or physician’s bag.
Prescriptions for Controlled Drugs
Only those persons with a DEA registration number may issue a prescription for narcotics. This registration number must appear on all prescriptions for controlled substances. Schedule I drugs require approval by the Food and Drug Administration (FDA) and the DEA for use in research. The sale of these drugs is forbidden. Schedule II drugs require a special DEA order form that is completed in triplicate. One copy is kept in the physician’s records, one copy is sent to the narcotics supplier, and one copy is sent to the DEA. Because there is a high potential for abuse and addiction with these drugs, the prescription cannot be refilled. Physicians must take a written inventory of their drug supply every two years. All narcotics-dispensing records must be kept for a two-year period. It requires careful communication between the physician and patient to assure that the patient is not seeking narcotics prescriptions from multiple physicians. In some instances, pharmacies that maintain careful records have been able to pinpoint abuse.
The compounding, dispensing, and retailing of drugs is controlled by the Controlled Substances Act. Compounding is the combination and mixing of drugs and chemicals. For example, a pharmacist compounds a drug by filling a physician’s prescription that involves preparing and mixing medications. In general, most medications are compounded by the pharmaceutical companies. Hospital-based pharmacists may have to compound certain medications, as for example, for children’s dosages. Dispensing is defined as distributing, delivering, disposing, or giving away a drug, medicine, prescription, or chemical. Most state statutes authorize professionals, such as nurses, nurse practitioners, or physician assistants to dispense drugs. For example, hospital-based nurses may dispense to their patients medications that have been prepared by a pharmacist, if they have a physician’s order. However, nurses may not enter a hospital pharmacy and remove drugs/medications from the hospital’s floor stock in order to carry out a physician’s orders. Retailing is the legal act of selling or trading a drug, medicine, prescription, or chemical.
The term “drug,” in most state statutes, is similar to the definition found in the Federal Food, Drug, and Cosmetic Act. This states that a drug is intended to affect the structure or function of the body of man or other animals. When applying this definition, the courts have decided that aspirin, laxatives, vitamin and mineral capsules, and whole human blood can be considered drugs under certain circumstances. Therefore, when handling these drugs, even aspirin, nurses and other professionals must be aware that they cannot be compounded or retailed. And a nurse can only dispense these drugs with a physician’s order. This means that if a hospitalized or nursing home patient asks a nurse for an aspirin it cannot be dispensed without a prescription from the physician. ( Figure 7.2 )
Figure 7.2 Explaining Drug Safety to a Patient
© Cultura RM/Alamy
A violation of the Controlled Substances Act is a criminal offense. The penalties range from a fine to a long prison sentence.
PROTECTION FOR THE EMPLOYEE AND THE ENVIRONMENT
Employee Assistance Programs (EAPs)
An Employee Assistance Program is a service provided by many institutions, such as hospitals and corporations, for all of their employees and employees’ family members. An Employee Assistance Program (EAP) may be defined as a management-financed and confidential counseling and referral service. It is designed to help employees and/or their family members assess a problem, such as alcoholism or marital strife, develop a plan to resolve personal problems, and determine the appropriate resources to assist in the resolution process. The EAP is geared toward helping employees maintain their job performance while attempting to resolve the difficulty. It is generally administered and staffed by experienced professionals who are trained to understand personal problems and their relation to job performance.
It is estimated that personal problems cost the U.S. economy $70 billion annually. Nearly half of this cost, $30.1 billion, is related to alcohol and/or drug abuse and the resulting loss of productivity. The Department of Health and Human Services estimates that
· 4.0 percent of the employed population use some form of illegal drugs daily.
· 5 to 10 percent of the workforce suffer from alcoholism. These substance-abusing employees are absent from work 16 times more often than the average employee, have four times more home accidents, use a third more sickness benefits, and have five times more compensation claims.
A “troubled” employee also means a supervisor will have a problem, and productivity may decline for both employees. The types of problems that an EAP can help with are substance abuse (alcoholism and drug abuse), stress-related (depression and anxiety), family and marital, psychological, and job-related (interpersonal and burnout).
It is important to remember that only trained, objective professionals should counsel employees regarding their personal problems.
Without an effective way to deal with employee problems, a healthcare supervisor may confront the employee, accept continued excuses, provide inadequate counseling, reassign tasks, give verbal warnings, demote or transfer the employee, give a final warning, and eventually resort to termination of the employee. By using an effective EAP, the supervisor
· Continues to supervise the employee’s job performance.
· Receives feedback of the first appointment from the EAP (subsequent appointment counseling sessions are not reported back to the supervisor due to confidentiality issues).
TABLE 7.6 Warning Signs That an Employee Needs an EAP
· Attitude changes
· Decrease in output
· Inability to carry his/her load
· Persistent lateness in completing tasks
· Lowered quality of work
· Increase in accidents or near accidents
· Repeated safety violations
· Excessive tardiness
· Repeated early departures
· Excessive absenteeism
· Prolonged lunch hours or breaks
· Mysterious absences from workstation
· Decline in personal appearance
· Mood changes
· Conflicts with coworkers
· Increase in personal phone calls
· Increased use of medical services
· Calls from creditors
· Garnishments of wages
· Notes improved performance or states the consequences of poor performance.
· Consults the EAP for suggestions of how to work with a difficult employee.
· Does not diagnose.
· Follows disciplinary documentation procedures.
· Is free to focus on job performance.
· Continues to talk with the employee, but does not provide counseling.
See Table 7.6 for warning signs that an employee needs an EAP.
Confidentiality is essential for the success of any EAP. Employees who have confidence in the medical staff may discuss personal problems with physicians and nurses. Many of these problems are those that an EAP staff is especially trained to handle, such as alcoholism, drug abuse, and marital problems. If it is necessary for a medical unit, such as in a hospital setting, to receive feedback on the employee condition, then the employee must sign a release allowing the EAP counselor to communicate with the medical unit.
While it is preferable that employees leave their personal problems outside of the workplace, this is often difficult to do. All healthcare workers must have empathy for each other, while still respecting an individual’s privacy ( Figure 7.3 ).
Hospitals, dental practices, veterinary clinics, laboratories, nursing homes, medical offices, and other healthcare facilities generate 3.2 million tons of hazardous medical waste each year. Much of this waste is dangerous, especially when it is potentially infectious or radioactive. There are four major types of medical waste: solid, chemical, radioactive, and infectious.
Solid waste is generated in every area of a facility, including administration, cafeterias, patient rooms, and medical offices. It includes trash such as used paper goods, bottles, cardboard, and cans. Solid waste is not considered hazardous, but it can pollute the environment. Mandatory recycling programs have assisted in reducing some of the solid waste in the United States.
Chemical wastes include germicides, cleaning solvents, and pharmaceuticals. This waste can create a hazardous situation—a fire or explosion—for the institution or community. It can also cause harm if ingested, inhaled, or absorbed through the skin or mucous membranes.
Figure 7.3 Nurse Working in an Employee Assistance Program
© Ann Cutting/Alamy
New guidelines from the U.S. Food and Drug Administration advise that non-narcotic drugs should not be flushed down the toilet unless information on the drug label specifically instructs one to do this. Ideally, they should be taken out of their original container and then mixed with substances such as coffee grounds to make it undesirable for anyone going through trash. They can then be placed in a sealable bag or empty can and discarded.
Medical personnel have a duty to refrain from pouring toxic, flammable, or irritating chemicals down a drain. These chemicals should be placed in sturdy containers or buckets and then removed by a licensed removal facility. Chemical wastes must be documented on the Material Safety Data Sheet (MSDS) , which also provides specific information on handling and disposing of chemicals safely. Clinical laboratories, such as those used by nursing and medical assistant students, must also document their use of chemicals.
Don’t flush medications down a toilet unless specifically instructed on the label to do so. Drugs can kill bacteria in septic systems and pass largely untouched through sewage treatment plants. Once in the landfills, drugs can trickle into groundwater.
Radioactive waste is any waste that contains or is contaminated with liquid or solid radioactive material. This waste must be clearly labeled as radioactive and never placed into an incinerator, down the drain, or in public areas. It should be removed by a licensed removal facility.
Infectious waste is any waste material that has the potential to carry disease. Between 10 and 15 percent of all medical waste is considered infectious. This waste includes laboratory cultures as well as blood and blood products from blood banks, operating rooms, emergency rooms, doctor and dentist offices, autopsy suites, clinical training laboratories, and patient rooms. All needles and syringes must be placed in a specially designed medical waste container. The three most dangerous types of infectious pathogens (microorganisms) found in medical waste are hepatitis B virus (HBV), hepatitis A virus (HAV), and the HIV, which causes AIDS.
Infectious waste must be separated from other solid and chemical waste at the point of origin, such as the medical office. It must be labeled, decontaminated onsite, or removed by a licensed removal facility for decontamination.