Unauthorized actions by medical students can be either the issuance of unauthorized orders to other health care personnel or direct actions by the student. The student who gives an order poses a problem only if the order is carried out without authorization by the supervising physician. Proper staff education will limit the extent of this problem.
The problem of medical students acting on their own is more difficult to control but is of sufficient legal consequence that it must be prevented. A medical student may not legally administer medications or perform procedures without authorization from a licensed physician. Proper drug inventory control system will limit the ability of medical students to administer unauthorized drugs, but the performance of unauthorized procedures is more difficult to control.
Procedures that require specialized equipment may be controlled through inventory procedures (placement of central venous lines, or example), but the only effective control over procedures that do not require special equipment is an observant nursing staff. There are no circumstances, other than life-threatening emergencies, where it is permissible for procedures to be performed without a physician's orders. Since the medical student's orders are not valid until they have been cosigned, the nursing personnel can eliminate most unauthorized procedures by checking the physician's orders.
The final check on procedures initiated by medical students is simple observation by the nursing staff. The nurses do not need to "spy" on the students, but they should be encouraged to note their comings and goings and behavior in the appropriate medical records. On occasion, this has resulted in the detection of extremely dangerous and totally unexpected behavior. One example involved a medical student who had a reputation for being an expert at drawing blood. Whenever no one else could get a blood sample from a patient, someone became suspicious and clandestinely observed the student drawing a blood sample from a patient. The student was promptly dismissed when it was discovered that the student was drawing the blood by sticking a needle into the patient's heart. While this type of intentional act cannot be anticipated, it illustrates the need for careful investigation of unusual behavior by medical students while they are seeing patients.
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