NURS 6521 Week 2 Prescriptive Authority Analysis Example

Hydralazine for Hydroxyzine: Legal, Ethical, and Process Analysis of a Look-Alike Prescribing Error by a Pennsylvania Nurse Practitioner

Student Name

College of Nursing, Walden University

NURS 6521: Advanced Pharmacology

Instructor Name

Month Day, Year

Hydralazine for Hydroxyzine: Legal, Ethical, and Process Analysis of a Look-Alike Prescribing Error by a Pennsylvania Nurse Practitioner

The Scenario

The events below are fictional. A family nurse practitioner in a Pennsylvania primary care practice saw a 58-year-old woman for chronic itching from atopic dermatitis that was disturbing her sleep. The plan was hydroxyzine at bedtime. In the electronic health record, the nurse practitioner typed "hydr" into the medication search field, and the drop-down list displayed hydralazine directly above hydroxyzine. Hydralazine, an antihypertensive vasodilator, was selected and signed. The pharmacy filled it as written. The patient took the first dose that evening, woke at night lightheaded and with a pounding headache, and took a second dose the next evening. The practice's follow-up call two days later, made to ask about her sleep, revealed that she had felt faint when standing and that the bottle said hydralazine. She had no lasting harm; her blood pressure normalized within a day of stopping the drug.

Legal Considerations

Prescriptive authority is granted state by state

There is no national license to prescribe. Each state decides through its nurse practice act and board regulations whether advanced practice registered nurses may prescribe, which drugs they may prescribe, and under what conditions. Some states grant full practice authority, allowing nurse practitioners to prescribe independently after licensure; others require a collaborative or supervisory arrangement with a physician (Rosenthal & Burchum, 2021). An analysis of any prescribing error therefore has to begin with the rules of the state where the prescription was written.

The Pennsylvania framework

In Pennsylvania, nurse practitioners are licensed as certified registered nurse practitioners, and their practice is governed by the Professional Nursing Law and the State Board of Nursing's regulations for certified registered nurse practitioners, found in 49 Pa. Code chapter 21, subchapter C. Pennsylvania is not a full practice state. A nurse practitioner who prescribes must do so under a written collaborative agreement with a physician, which identifies the categories of drugs the nurse practitioner may prescribe and must be filed with the Board. The nurse practitioner is personally accountable for each prescription written; the collaborative agreement defines the scope of prescribing but does not transfer responsibility for an individual order to the collaborating physician.

Applied to this scenario, hydralazine and hydroxyzine both fall within categories that primary care collaborative agreements ordinarily include, so the error was not a prescription outside the nurse practitioner's authority. It was an error within authority, which places the legal questions on the standard of care rather than on scope. A prescription that does not match the documented assessment and plan is a deviation from the standard of care, and if harm results, the prescriber is exposed to a negligence claim and to Board review. The Board's concern would include whether the error was disclosed, documented, and addressed.

Federal authority for controlled substances

State authority governs prescribing in general, but controlled substances also require federal registration. Under the Controlled Substances Act, a practitioner who prescribes drugs in Schedules II through V must hold a registration with the Drug Enforcement Administration, and the regulations at 21 C.F.R. part 1301 set out registration requirements. Federal registration depends on state authority: the DEA registers a nurse practitioner only for the schedules the state permits. Neither drug in this scenario is controlled, so federal registration is not at issue here, but the distinction explains why a nurse practitioner's authority can differ by schedule even within one state.

Ethical Considerations

At the moment of discovery, the nurse practitioner faced a choice that is common after a harmless error: call the patient, correct the prescription, and describe the change as an adjustment, or tell her plainly that a mistake had been made. The pull toward quiet correction is real. The patient was unharmed, disclosure is uncomfortable, and it may damage her trust in the practice.

Two principles argue against that choice. Veracity, the duty to tell the truth, requires that she be told what happened, because it happened to her, and a patient cannot make informed decisions about her own care, including whether to continue with this practice, while missing a material fact about it. Nonmaleficence adds a practical reason: she needs to know which drug she took, which symptoms it caused, and what to do if they recur, and a vague explanation withholds information that protects her. The ANA Code of Ethics places the nurse's primary commitment with the patient and expects nurses to be accountable for their own practice (American Nurses Association [ANA], 2015). Patients themselves want disclosure. In a study of attitudes toward medical errors, patients wanted to be told about all harmful errors, including minor ones, and wanted an explanation of what happened, why, and how recurrence would be prevented (Gallagher et al., 2003).

The decision in this analysis is that the patient is told, promptly and specifically: which drug she received, why it was wrong, what effects it caused, that the error was the prescriber's, and what the practice will change. An apology is offered. The error is documented factually in the record and reported through the practice's internal safety reporting system. Disclosure of this kind is also consistent with legal risk management, since concealment discovered later is far more damaging than an honest account given at the time.

Preventing Recurrence

Prevention proposals are useful only if they target the step where this error occurred, which was the selection of a drug from an alphabetical drop-down list after a three-letter search. Hydralazine and hydroxyzine appear on the Institute for Safe Medication Practices list of confused drug names for exactly this reason (Institute for Safe Medication Practices [ISMP], 2023). Two changes address that step directly.

First, the practice will ask its electronic record vendor to enforce a minimum search length before displaying results and to display known look-alike pairs with tall man lettering, which capitalizes the letters that differ (hydrALAZINE, hydrOXYzine). Requiring more letters narrows the list, and tall man lettering makes the difference visible at the moment of selection.

Second, the practice will require the indication to be entered with every new prescription, with the record displaying it on the order and transmitting it to the pharmacy. An order reading "hydralazine, for itching" makes the mismatch visible to the prescriber at signing and to the pharmacist at verification, adding two independent checks that did not exist in this scenario. Generic advice to double-check orders would not have changed the outcome, because the prescriber believed the order was correct; a change that exposes the mismatch between drug and indication would have.

Conclusion

This error was within the nurse practitioner's prescriptive authority under Pennsylvania's collaborative framework, so the legal questions concern the standard of care and the response to the error rather than scope. Ethically, veracity and nonmaleficence require disclosure, and the patient is told what happened and what will change. The two process changes target the drop-down selection that produced the error and add checks at signing and dispensing that would catch the same mistake if it happened again.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Nursesbooks.org.

Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA, 289(8), 1001-1007. https://doi.org/10.1001/jama.289.8.1001

Institute for Safe Medication Practices. (2023). ISMP list of confused drug names. https://www.ismp.org/recommendations/confused-drug-names-list

Registration of Manufacturers, Distributors, and Dispensers of Controlled Substances, 21 C.F.R. pt. 1301 (2024).

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier.

State Board of Nursing: Certified Registered Nurse Practitioners, 49 Pa. Code ch. 21, subch. C (2024).