Saturday cover: what an unlicensed assistant may and may not do
A small three-room practice is staffed on Saturdays by one therapeutically qualified optometrist, Dr. N, and two optical assistants who hold no clinical licence. Both assistants have completed the practice's in-house "clinical skills" module and routinely work patients up while Dr. N moves between rooms. Last Saturday, while Dr. N was fitting a rigid lens in room 3, assistant A performed non-contact tonometry on Mr. K, aged 68, instilled proxymetacaine and tropicamide from the practice's diagnostic set, and recorded "glaucoma check - pressures 22/21, needs drops". Assistant B then selected a monthly silicone hydrogel lens for a walk-in customer, quoted a price, and told her she could start wearing them that day. Mr. K later developed a painful red eye and headache and was treated at an emergency department for a corneal abrasion. Dr. N learns all of this on Monday, when Mr. K's daughter telephones to complain and asks what the assistants were doing.
1. Which of the tasks performed by assistants A and B are, in principle, delegable to unlicensed personnel, and which are not? State the legal test you would apply.
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The test. Delegation is not created by in-house training or by the doctor's comfort level. It is defined by the optometry Act and the board's rules, which list acts reserved to licenseholders (diagnosis, prescribing, fitting and prescribing contact lenses, instillation of drugs) and, separately, tasks that unlicensed staff may perform under stated conditions - often only under direct, on-site supervision of a licensed optometrist. Training establishes competence, not authority.
- Non-contact tonometry - commonly delegable as a measurement where the rules permit it, provided the optometrist reviews and owns the interpretation. A reading recorded as a "glaucoma check" with a management statement is not delegable, because it is assessment and diagnosis.
- Instilling proxymetacaine and tropicamide - a restricted act in most jurisdictions. Even where an assistant may instil a diagnostic agent, it requires a patient-specific order and the required level of supervision. Neither existed here, and neither anterior chamber depth nor angle risk was assessed before dilation.
- Selecting and starting a contact lens - reserved. The assistant may quote prices, verify a parameter against an existing valid prescription, or teach handling after the optometrist has finalised the fit. She may not choose the lens or authorise wear.
Conclusion: A exceeded scope twice; B exceeded scope on the fitting. The optometrist remains professionally responsible for acts carried out within her practice, whatever the assistant's training record says.
2. What are Dr. N's immediate obligations to Mr. K once she learns what happened?
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Patient first. Mr. K needs a documented assessment of the painful red eye and headache, not a phone reassurance: vision, staining, anterior chamber, lid and corneal status, and a plan for review or referral. The ED treated him, but Dr. N should confirm the diagnosis and record that she did so.
Disclosure. Tell Mr. K what happened - that an unlicensed assistant instilled drops and performed the measurement without a doctor's order. An explanation and apology are expected. Whether to make admissions of fault is a separate question: follow the indemnifier's guidance on wording and avoid speculating about causation.
Records. Create a new, dated and timed entry describing the call, the review and what was said. Do not edit or delete Saturday's entries; the record as it stands is evidence, and an electronic audit trail will expose any change.
The daughter. A family relationship does not authorise discussion of his care. Ask Mr. K whether he consents to her being told, and record his answer.
Notifications. Inform the professional indemnifier promptly - notification is usually a condition of cover. Consider whether the jurisdiction requires a board report for an adverse event or for an assistant practising outside scope. Suspend the assistants' clinical duties pending review, without prejudging the outcome.
3. What system changes and professional responsibilities follow from the incident?
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- Written delegation policy listing each task, the required supervisory level, and named staff whose credentials have been verified. "We all muck in" is not a policy.
- No standing orders for drugs. Instillation only on a patient-specific order, with an angle/anterior chamber check built into the protocol before any mydriatic.
- Scheduling reform - the incident happened because one doctor was expected to supervise two simultaneous work-ups. Either add licensed cover or slow the clinic.
- Incident reporting and review with a no-blame analysis feeding back into training, plus a near-miss log.
- Competency sign-off for unlicensed staff, repeated annually and after any change in the rules.
- Audit of records where assistants worked up patients, looking for delegated-task entries with no doctor's countersignature.
On responsibility: the regulator's interest is in the practitioner who permitted the arrangement, not only the assistant. If the audit shows this was routine rather than a one-off, a proactive self-report to the board is generally a better position than waiting for a complaint to arrive. Keep the audit, the new policy and the staff briefing minutes - they are what shows remediation was real.