By Richard Steinecke,
Counsel, Steinecke Maciura LeBlanc
The Regulated Health Professionals Act, 1991 names 14 controlled acts that may only be performed by an authorized regulated health professional. That said, any controlled act can be delegated by a regulated health professional who has the authority to do so to someone who is not authorized, as long as delegation is consistent with College policies. Pharmacists may consider delegating the performance of a controlled act where it is in the patient’s best interest.
Using the case below, I explore a series of questions pharmacy professionals can apply in their own decision-making when considering delegation.
Delegation is a process whereby a regulated health professional authorized to perform a controlled act under a health profession Act confers that authority to someone who is not authorized.
Your busy community pharmacy has an increased demand for injectable vaccine administration (Schedule 3). You cannot keep up with the demand as it disrupts the work behind the pharmacy counter. A retired nurse (who is no longer registered with the College of Nurses of Ontario) is willing to assist you with the vaccinations. Can you delegate this task to the individual? If so, what are your responsibilities and accountabilities?
Asking the Right Questions
Delegation of a controlled act has numerous legal and professional implications. To assist in navigating this activity, I propose using the following decision tool to support registrants in determining when and how to delegate a controlled act.
Is It a Controlled Act?
Delegation only applies to controlled acts. Activities that are not controlled acts (e.g., managing vaccine inventory) are still important and, indeed, dangerous if not done properly. However, these activities are assigned, not delegated. They are also governed by a separate set of principles, including supervision (to be discussed in a future article).
Administering a substance to a patient by injection for any health-related purpose, including vaccine administration, is a controlled act. For a list of all 14 controlled acts for regulated healthcare professionals see section 27 of the Regulated Health Professions Act.
Are You Authorized to Perform the Controlled Act?
You can only delegate a controlled act if you are authorized under the Pharmacy Act, 1991, s. 4 (authorized acts) to perform it. If you are not authorized under the legislation to perform a particular controlled act, you cannot delegate it.
If you are delegated to perform a procedure by a physician (e.g., administer a substance not listed in the regulations under the Pharmacy Act), you cannot “subdelegate” it. In other words, a controlled act that was originally delegated to you cannot be further delegated to a staff member.
Pharmacists, pharmacy interns and registered pharmacy students are authorized to administer a vaccine by injection for eligible patients, but not all have the authority to delegate it.
Are You Permitted to Delegate the Controlled Act?
Not everyone authorized to perform a controlled act is permitted to delegate it. For example, the regulations made under the Pharmacy Act specify that pharmacy interns, registered pharmacy students and pharmacy technicians are not permitted to delegate controlled acts. Only pharmacists listed in Part A of the public register are permitted to do so.
Are You Capable of Performing the Controlled Act?
Even if you are authorized and permitted to perform the controlled act, including vaccine administration by injection, you should not delegate it unless you can perform it appropriately and competently as a part of your regular practice.
Having these skills and competencies are necessary to enable you to safely and effectively delegate it to others. You have certain responsibilities associated with the delegation that you cannot fulfill without having the ability to perform the controlled act yourself. Delegation of a controlled act is not a solution to gaps in your own skills.
The College has adopted a number of standards (including Model Standards for Pharmacy Compounding of Non-Hazardous & Hazardous Sterile Preparations) that can assist registrants in determining the level of competency required in various settings.
Is the Person You Are Delegating to Capable of Performing the Controlled Act?
You have a responsibility to ensure that the person to whom you are delegating the controlled act has the knowledge, skills and competencies to perform it. While you can rely to some extent on their professional status and training, you cannot rely only on that for current competence.
In the scenario above you would want to ensure that the retired nurse is familiar with screening the patient’s suitability for the vaccination, is able to appropriately administer the vaccine, can practice proper infection prevention and control measures and is able to manage the post injection monitoring and procedures.
This duty to assess the person’s capabilities is even higher where the person receiving the delegation has never been registered as a healthcare professional.
Is the Person You Are Delegating to Authorized to Receive the Delegation?
Not everyone is permitted to accept a delegation. For example, a pharmacy student, intern, or technician may have terms, conditions and limitations on their certificate of registration limiting their ability to perform certain activities including controlled acts. Delegation cannot be used to circumvent those restrictions.
The person accepting the delegation does not need to be a registered healthcare professional so long as you have assured yourself as to their capabilities. However, if they are registered, you should ensure that there are no restrictions on their ability to accept the delegation. While rare, those restrictions can be general (e.g., in the regulations for registrants of that profession) or specific (e.g., a term, condition, and limitation on their certificate of registration).
In this case, the retired nurse is no longer registered with the College of Nurses of Ontario (CNO). However, it would be prudent to review the CNO public register information to confirm this and ensure that their registration was not associated with unprofessional conduct, incompetence or incapacity.
Is the Delegation in the Patient’s Best Interest?
Pharmacists, as healthcare professionals, must always put patients’ best interests first, including prioritizing them over any business or financial interests. As stated in the College’s Medical Directives and the Delegation of Controlled Acts policy: “a registrant must use professional judgment when accepting delegation to evaluate the associated risks and determine whether delegation is in the best interest of the patient.”
The same principle applies to making a delegation. For example, routinely delegating the entire dispensing process to unregistered persons would attract professional liability.
However, in the scenario described above, there may well be circumstances where delegating to someone (i.e., the retired nurse) the administration of vaccinations to patients is in their best interest. It is an important health prevention step that might best be done by bringing in a skilled person who can solely focus on administering vaccines and take the time needed for each patient while following a carefully designed checklist.
Have You Specified the Delegation?
The delegation needs to be clear. As such, you would want to set out in writing who is making the delegation (i.e., you), who the delegation is to (i.e., in this case the retired nurse), for what procedure (i.e., details of administering vaccinations by injection) and to whom (i.e., either a named patient, called a direct order, or a clearly defined category of patients, called a medical directive).
Any intended restrictions should be contained in the delegation. For example, in the scenario above, the delegating pharmacist may wish to restrict the delegation to the pharmacy premises.
The delegation should include an explicit description of the expectations surrounding the performance of the controlled act. For example, this would include performing patient suitability screening, obtaining informed consent, respecting privacy, maintaining infection control, and completing appropriate documentation.
It is difficult to conceive of circumstances where a pharmacist would delegate the performance of a controlled act except in writing.
Are You Prepared to Be Accountable for the Performance of the Controlled Act?
The delegator of the controlled act retains accountability for its performance. Accountability cannot be avoided by following all of the steps described above. If a mistake is made, the delegator is responsible. As such, the delegator will wish to employ an appropriate level of oversight.
There are circumstances where a pharmacist can delegate the performance of a controlled act in the patient’s best interest. However, before doing so, the pharmacist should consider using the decision tool set out above.
- If you are not authorized under the legislation to perform a particular controlled act, you cannot delegate it.
- Even if you are authorized and permitted to perform the controlled act, you should not delegate it unless you can perform it appropriately and competently as a part of your regular practice. Delegation of a controlled act is not a solution to gaps in your own skills.
- Pharmacists, as healthcare professionals, must always put patients’ best interests first, including prioritizing them over any business or financial interests.
- The person accepting the delegation also is accountable. Thus, there is a shared accountability in that sense. However, the person making the delegation cannot transfer their own accountability to the person accepting the delegation. ↑