A case study showing an example of how medication administration errors and recording errors led to a nurse facing the Nursing and Midwifery Council’s fitness to practise panel
you are the panel
Nurse A administered insulin without checking Patient A’s medication chart; administered an overdose of insulin to Patient A and failed to complete a CIRIS report. She also administered 19 units of insulin to Patient B when 8 units were prescribed. She recorded the administration of insulin to Patient B on an out-of-date medication record administration chart.
Nurse A was working as a community nurse for a care home. The team at the care home did not use paper records and worked from an electronic system. In 2017, Nurse A attended a care home where she had been allocated Patient A, who required the administration of insulin.
On that particular day the electronic recording system used had not been working and staff had used the back-up paper-based system.
The following day Nurse A again attended at the same care home. The electronic system had been fixed and was working again. However, Nurse A did not turn her tablet on to check this and incorrectly assumed that she had been allocated the same patients. Nurse A attended Patient A as she had the previous day, and administered insulin to him allegedly without first checking his medication chart. Patient A allegedly received almost double the prescribed dose of insulin.
Later in 2017, Nurse A was allocated a home visit to Patient B, who required the administration of insulin. She administered insulin and allegedly recorded it in an out-of-date medication chart from nearly two years before.
At the hearing
The panel found all the charges proved. Nurse A did not attend the hearing. The panel accepted that Nurse A had experienced technical difficulties with her tablet the previous day, so assumed that there would be ongoing difficulties. The panel was of the view that she should have checked Patient A’s paper medication chart prior to administering insulin. Had she done so she would have been made aware that Patient A had already received his dose of insulin.
It was alleged Patient A was administered a double dose of insulin due to Nurse A’s failure to check his medication chart. Nurse A stated that she went to speak to the senior carer and explained what had happened. The panel noted that in Patient A’s medication chart, beside her signature, she had written “by accident”. In light of the evidence before it, the panel was satisfied that Nurse A administered an overdose of insulin to Patient A.
Witness 1 said that instead of recording on the current chart, Nurse A recorded on a chart that was almost two years old that she had administered 19 units of insulin. Witness 1 said that when she interviewed Nurse A about this, she was adamant that she had administered 8 units. Witness 1 said that it was impossible to say whether Patient B was administered with 8 units of insulin, as prescribed, or 19 units of insulin, by error. Patient B had old prescription charts in her home. Nurse A said there was no space for her to record the insulin on the current chart so she wrote it in an old chart.
By administering medication to patients on two separate occasions without checking the necessary medication charts, Nurse A put patients at unwarranted risk of serious harm. She also failed to escalate the fact that she had recorded the medication administration on an out-of-date chart. The panel was of the view that these actions would be viewed by fellow members of the profession as falling far below the standards expected. The panel found that Nurse A’s actions amounted to misconduct.
Results of the fitness-to-practise panel
The ftp panel can impose four different sanctions:
- Caution: the nurse or midwife is cautioned for their behaviour, but is allowed to practise without restriction
- Conditions of practice: this will prevent a registrant from carrying out certain types of work or working in a particular setting, it may require them to attend occupational health or do retraining. The order can be applied for up to three years and must be reviewed by an FTP panel again before expiry
- Suspension: the nurse or midwife will be suspended from practice for a period of initially not longer than one year, but this can be extended after review by an FTP panel
- Striking off: a nurse or midwife is removed from the register and not allowed to practise in the UK. The nurse or midwife must apply to be readmitted to the register