Director of Proceedings v Draper

Health Practitioners Disciplinary Tribunal Decision No. 534/Nur 12/227D (30 April 2013)

The Director of Proceedings brought a disciplinary charge of professional misconduct against a registered nurse before the Health Practitioners Disciplinary Tribunal. The case concerned a nurse who mistakenly gave a patient medication that had been prescribed for another patient. The medication was contraindicated for the patient who received it and the patient died within hours of it being administered. The nurse discovered her error shortly after she had administered the incorrect medication, but failed to raise the alarm or take any action to come to her patient's aid by notifying a medical practitioner of the error.

Patient A was admitted to the high dependency unit of a cardiac ward. He was terminally ill and had been experiencing delirium, shortness of breath and a slow heartbeat. The nurse caring for Patient A went to obtain some sedation for him after he had been displaying difficult behaviours associated with his delirium. The nurse decided to administer Patient A his dinner time medications at the same time as the sedation and proceeded to withdraw the patient's charted medications from the medication dispensing system, the Pyxis.

Unfortunately, without the nurse's knowledge, the medication chart for another patient (Patient B) was pinned within the chart the nurse was using to withdraw Patient A's medication. The nurse withdrew Patient A's medications, flipped over the page of the chart and withdrew the medications prescribed for Patient B. The nurse did not check the patient name at the top of the chart, nor did the nurse heed the warning on the Pyxis that the medications had not been prescribed for Patient A. One of the medications had known negative effects on heart rate and was therefore contraindicated for Patient A.  The nurse later accepted before the HPDT that her failure to check the medication and who it was prescribed for amounted to professional misconduct.    

The nurse then administered the medication to Patient A, but did not record in the medical notes that she had administered to him the extra medications that were not prescribed for him. Shortly after administering the incorrect medicine to her patient, the nurse discovered her error. However, the nurse did not take any action to address the medication error or notify a medical practitioner of it. The nurse therefore failed to come to the aid of her patient. Patient A passed away two hours later.  The nurse did not inform anyone of the error until two days later. The nurse accepted that her failure to report the medication error to a medical practitioner in a timely manner amounted to professional misconduct.

In a decision dated 30 April 2013 the Tribunal held that the case would ordinarily have warranted the imposition of a suspension of 12 months but this was not imposed in this instance because the nurse had not been practising since September 2010 (nearly two and a half years).  Conditions were imposed on the nurse in the event that she returns to practice. These relate to training in pharmacology and professional ethics, supervision in the context of administration of medicines, and that she refrain from coordinator/leader roles. The Tribunal also censured the nurse and imposed an award of costs.    

The Tribunal's decision is available at: https://www.hpdt.org.nz/Charge-Details?file=Nur12/227D


Last reviewed February 2019