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What should happen to a nurse who incorrectly distributed medicines to residents?

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In this month’s case, a nurse failed to correctly distribute medicines to residents in a care home. The charges brought against her led to the nurse being the subject of a fitness to practise hearing

you are the panel

you are the panel

The charge

That Nurse A, a registered nurse recorded the application of a Matrifen pain relief patch to Resident B when this had not been applied; failed to record the administration of one or more medications to one or more of the following residents: Resident E, Resident G and Resident J. She failed to record the administration of one or more medications to one or more of the following residents: Resident B, Resident D and Resident F. Following administration of insulin to Resident D she failed to ensure that the used needle was placed into a sharps bin. Following administration

of antibiotics to Resident K she failed to ensure that the resident swallowed the tablets.

The background

In 2016, Nurse A was working on nightshifts at a care home. At the start of her shift, she received handover from Ms 1 who provided Nurse A with a suggested routine.

The following morning, Nurse A provided handover to Ms 2 and told her that a number of the 18 residents upstairs had not received their morning medications. Ms 2 agreed to administer medications to those residents that Nurse A had not yet seen. Ms 2 was approached by a Ms 3, and handed a Matrifen pain relief patch. Nurse A informed Ms 2 that she had intended to apply the patch to Resident B but had then lost it and, due to the shift being busy, had forgotten about it. 

Ms 2, upon starting the medication round, found that there were a number of gaps on medication administration record (MAR) sheets. This meant that she could not determine whether medications had been administered to residents.

Ms 2 then entered Resident K’s room and found two antibiotic tablets, which appeared to have fallen from the resident’s mouth immediately after administration. Ms 2 went into Resident D’s room and found an uncapped insulin needle. The resident’s insulin would have been administered early in the morning, meaning that the needle had been in the resident’s room for five hours. 

After completing the medication round, Ms 2 spoke to Ms 1 regarding the medication issues she had discovered. Ms 1 then reviewed the MAR charts for all residents, the controlled drug book, and the stock of controlled drugs. For the majority of medications, Ms 1 was unable to confirm whether the medication had been administered but not signed for or not administered.

At the hearing

Nurse A admitted to the facts alleged in the charges. The panel found there was no case to answer for the charge related to Resident F. 

Although there was no actual harm, there was a risk to the residents and to colleagues. The panel noted that this was not simply scheduled medication but a “controlled” drug. The panel was of the view that there was a potential risk of cross infection and needle stick injury as a result of non-disposal of a used needle in the sharps bin. 

The panel considered the failure to record and administer medication. Although there was no actual harm, there was still a risk to the residents. The panel observed that it was important to record accurately what has, or has not, been provided to the patient to ensure adherence to treatment regime and inform colleagues.

The panel considered the final charge and was not satisfied that this charge amounted to misconduct as Nurse A had not been informed of the resident’s inability to swallow tablets. The panel considered that she asked the resident, who confirmed that she had swallowed the tablets.

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

Share what you believe is the right action for the NMC panel to take below and then find out what they decided: Final panel decision and reasons

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