Delegated Authority, Advance Practice Nurses, and Patient Safety

Working with physicians, advance practice nurses (APNs) are integral parts of the health care team. With authority delegated by a physician under state law, APNs provide services safely permitted by their education, training, and skills. In this model, APNs serve as extensions of a physician's practice, through the authority of the physician's license. The delegating physician retains authority over - and ultimate responsibility for -his or her patients. Texas law wisely regulates how physicians' may delegate prescriptive authority to APNs. There are standards for the number of APNs or PAs to whom a physician may delegate authority, requirements for the physician to actively supervise the APNs' actions, and specific protections for pediatric patients.

As part of a national effort to expand their scope of practice, APNs are asking the 2009 Texas Legislature to abandon the carefully balanced delegated model and replace it with an open-ended "prescriptive authority agreement" between a physician and an APN. These "liberally construed" agreements - with few requirements for supervision or collaboration - could jeopardize the health and safety of Texans. Neither the Texas Medical Board nor the Board of Nursing Examiners would have meaningful authority to investigate complaints or take disciplinary action for poor quality care. The proposal would eliminate necessary patient-protection standards for on-site physician supervision of APNs, physician review of patient charts, narcotics prescriptions, and pediatric care.

Medicine's 2009 Agenda

  • Ensure Texas Medical Board has proper oversight of physicians' delegation of prescriptive authority and other responsibilities to allied health practitioners.
  • Prevent any efforts to expand scope of practice beyond that safely permitted by non-physician practitioner's education, training, and skills.
  • Protect Texas' carefully balanced physician delegated model of care, which serves as the foundation for ensuring the physician retains authority over - and ultimate responsibility for - his or her patients.

Medicine's Messages

  • Physicians are responsible for coordinating the various components of health care as they are delivered by the health care team. We must focus on this coordination as Texas searches for safe ways to meet our shortage of health care professionals.
  • Proposed "prescriptive authority agreements" remove the safety standards inherent in the delegated authority model. They also eliminate patient protections provided by the Texas Medical Board, hospital medical directors, and the hospital medical staff.
  • Prescribing medications, including dangerous drugs and controlled substances, should be done only under the supervision of a physician who is accountable, legally and ethically, for patient care.

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