NU743 Unit 7 Conflict Analysis, Vancomycin Dosing Example

Two Doses in Three Hours, Both Within Authority: An Interprofessional Conflict Analysis of a Nurse Practitioner's Vancomycin Order and a Pharmacist's Protocol Change for a Patient With MRSA Bacteremia

[Student Name]

Purdue University Global

NU743: Clinical Decision-Making and Collaboration

Unit 7 Interprofessional Conflict Analysis

[Instructor Name]

[Date]

The patient, clinicians and hospital are composite; doses, values and times are bracketed. Clinicians are identified by role only.

What Happened

Mr. [H.], [63], weighing [128] kg, was admitted with a bloodstream infection from a leg wound; blood cultures grew methicillin-resistant Staphylococcus aureus on hospital day [two]. His creatinine was [1.0] mg/dL on admission and [1.4] on day [three].

At [1300] on day [three], the hospitalist nurse practitioner, having seen a vancomycin trough of [11] mcg/mL, increased the dose to [1,750] mg every [12] hours, aiming for a trough of [15 to 20], the target she had learned in training.

At [1640], the clinical pharmacist, acting under the hospital's pharmacy-to-dose protocol for vancomycin, reviewed the order using Bayesian dosing software. With the rising creatinine, the software estimated that the new dose would produce a 24-hour area under the curve of about [720] mg·h/L. The pharmacist changed the order to [1,250] mg every [12] hours, estimated to give an area of about [520], and left a note in the record.

At [1800], the practitioner saw the change, concluded that the dose had been cut in a bacteremic patient, and restored her order, writing "do not change" in the comments.

At [1845], the pharmacist called her.

What Was Said

The exchange, attributed by role, was short. The pharmacist said: "The protocol lets me adjust vancomycin. At your dose his exposure is well above target and his kidneys are already worse." The practitioner said: "He has MRSA in his blood. I'm not going to underdose him because of a computer." Each later told a colleague that one line was the one they regretted. The pharmacist regretted opening with the protocol rather than the patient; the practitioner regretted the word "computer."

Who Had Authority

The conflict makes sense only when the sources of each clinician's authority are laid side by side. State law grants the nurse practitioner prescriptive authority, including for antibiotics. The state pharmacy practice act permits pharmacists to adjust drug doses under a protocol or collaborative practice agreement approved by the institution. The hospital's policy, approved by its pharmacy and therapeutics committee and medical staff, places vancomycin dosing under pharmacy-to-dose for all adult inpatients unless a prescriber opts out in writing. And the current consensus guideline for serious MRSA infections recommends dosing guided by the area under the curve, targeting a ratio of area to organism MIC of about [400 to 600], preferably estimated with Bayesian software, and advises against trough-only monitoring with targets of 15 to 20 because of the greater risk of kidney injury (Rybak et al., 2020).

Read together, the pharmacist's change was authorized by policy and consistent with the guideline, and the practitioner's order was within her license. Her "do not change" comment, however, was not a written opt-out under the policy, so the protocol technically still applied. Each could reasonably believe they held the dose.

The conflict was not between a right clinician and a wrong one, but between two authorized processes that nobody had designed to meet.

Why the Conflict Happened

A scoping review of conflict in health care found that it arises from factors at three levels: individual, such as differing knowledge or beliefs; interpersonal, such as communication styles; and organizational, such as unclear roles and structures (Kim et al., 2017). All three were present.

At the individual level, the practitioner had been trained on trough targets and did not know that the guideline had moved to area-guided dosing. At the interpersonal level, the pharmacist changed the order and left a note without calling, and the practitioner reversed it without calling; each communicated through the record rather than directly. At the organizational level, the protocol did not require the pharmacist to notify the prescriber before changing a dose, and the policy's opt-out process was not known to the hospitalist team.

What Each Clinician Could Have Done Differently

Both clinicians acted in good faith, and each had a choice point that could have prevented the conflict. The pharmacist could have called before changing the dose, since a reduction in a bacteremic patient was likely to surprise the prescriber, and could have led with the patient's rising creatinine rather than with the protocol. A short explanation of the area estimate would have given the practitioner a reason, not only a rule. The practitioner could have called before reversing the change, or at least read the pharmacist's note closely enough to see that the reduction was based on an estimated exposure well above target. Writing "do not change" in a comment field communicated her decision but not her reasoning, and it did not reach the pharmacist until the next review. In both cases, the record was used to deliver a decision that needed a conversation.

How It Was Resolved

The call at [1845] became a conversation once the pharmacist explained the area estimate and the practitioner explained her concern about underdosing in bacteremia. They agreed on a middle course: [1,500] mg every [12] hours, a Bayesian estimate of about [600], at the top of the target range, with levels the next morning and daily creatinine. The practitioner read the guideline that evening. His cultures cleared on day [five], and his creatinine returned to [1.1] by day [seven].

What Changed Afterward

Two changes followed. The pharmacy and therapeutics committee amended the protocol so that pharmacists call the prescriber before any dose change of more than [20] percent for a patient with bacteremia, and the hospitalist group added the protocol, its opt-out process and the current vancomycin guideline to its orientation for new clinicians. Both changes address the organizational factors, which were the ones most likely to repeat.

The national interprofessional competencies ask each profession to know what the other professions are responsible for and to talk with them in ways that lead to shared decisions (Interprofessional Education Collaborative, 2023). This conflict shows why: each clinician knew their own authority and not the other's.

What the Case Teaches

When a protocol and an order can both govern the same decision, conflict is built into the system, and it will surface on the busiest day, in the sickest patient, between two people who are each trying to do the right thing. The clinicians involved can resolve one episode by talking, but only a change in the protocol and in orientation prevents the next one.

References

Interprofessional Education Collaborative. (2023). IPEC core competencies for interprofessional collaborative practice: Version 3.

Kim, S., Bochatay, N., Relyea-Chew, A., Buttrick, E., Amdahl, C., Kim, L., Frans, E., Mossanen, M., Khandekar, A., Fehr, R., & Lee, Y.-M. (2017). Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review. Journal of Interprofessional Care, 31(3), 282-290. https://doi.org/10.1080/13561820.2016.1272558

Rybak, M. J., Le, J., Lodise, T. P., Levine, D. P., Bradley, J. S., Liu, C., Mueller, B. A., Pai, M. P., Wong-Beringer, A., Rotschafer, J. C., Rodvold, K. A., Maples, H. D., & Lomaestro, B. M. (2020). Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. American Journal of Health-System Pharmacy, 77(11), 835-864. https://doi.org/10.1093/ajhp/zxaa036