IV MEDICINE ADMINISTRATION Legal and Professional Issues

Why expand roles?

• Clinical need

• Nurses CAN - The NMC supports this growth in expertise

• Legislation supports this development

• Reduction in junior doctors working hours

• Ultimately it will benefit the patient

Four Arenas of Accountability

To the public

To the patient

To the employer

To the profession

Code of Conduct

• New Code launched 1st May 2008

• Competency• Consent• Delegation

The Code:

Standards of conduct, performance and ethics for nurses and midwives

PICTURE AWAITED

Competency

• Recognise & work within the limits of your competence

• You must have the knowledge & skills for safe & effective practice when working without direct supervision

Consent

• All individuals (adults aged 16 & over and children/young people who can give valid consent), with decision-making capacity, have a fundamental legal and ethical right to determine what happens to their own bodies

• No adult can validly give consent for another adult unless legally authorised to do so.

• It is not usually necessary to document a patient’s consent to routine and low-risk procedures,. However, if the consent may be disputed later, or if the procedure is of particular concern to the patient it would be helpful to do so.

Delegation

• You must establish that anyone you delegate to is able to carry out your instructions

• You must confirm that the outcome of any delegated task meets the required standards

• You must make sure that everyone you are responsible for is supervised and supported

Case Study

• Patient A had a urinary catheter in situ which was draining well, it was not felt that intake and output required monitoring

• The task of washing Patient A was delegated to HCSW who did this everyday for 4 days

• Patient A became very unwell - PTE • Further investigation – distended abdomen 4 L

urine drained. Swollen bladder pressing on her iliac arteries which caused DVT which lead to PTE

• Patient A later died as a result of PTE

Law & Nursing

• 2 Types of Law:

– Criminal Law (Public)

– Civil Law

(Patient)

Negligence – Elements

• For this action to be successful, 3 criteria must be established

– A duty of care is owed by the defendant to the plaintiff

– There is a breach in the standard of the duty of care owed

– This breach caused reasonably foreseeable harm.

Misconduct • 686,886 nurses on the register 2007• Scotland 10% of register but account for

only 6% of complaints• 1,624 complaints received 2007 17.8%

- Employer 50%- Public 15%- Police 23%

• Closed - 808 cases • Referred to conduct & competence

committee - 315 cases

NMC

• Maladministration of medicines represent 10.5% of all cases (3rd most common)

• Most common allegation is Dishonesty

• Other allegations include:• Patient abuse• Neglect of basic care / Unsafe clinical practice• Failure to maintain adequate records• Colleague abuse• Failing to report incidents / act in an emergency

Example Case

• Failed to attach an additive label to infusion of antibiotics

• Administered IV therapy to patient with no evidence of competency in IV Drug administration

• Hung bag of Vancomycin & failed to connect infusion but signed to say it had been given

• On the label of the bag of Vancomycin recorded patients name as Mary no other details

Example Case

• On 8 October 2004, administered a Patient Controlled Analgesia infusion of morphine to Patient A which had expired

• On 8 April 2005, administered Vancomycin to Patient C by way of a bolus injection when it should have been administered as an intermittent infusion

Conduct & Competency Committee

Stages:

I. Are the facts alleged proved?

II. Is it misconduct?

III. What is known about the practitioner’s previous history and in mitigation?

Conduct & Competency Committee Outcomes

• Strike name off register (52%)

• Caution 1-5 yrs (12%)

• No action taken (9%)

• Conditions of practise >3yrs (4%)

• Suspend registration >1yr (3%)

Right patient?

• Patient A awakened at 6 am and given RISEDRONATE 35mg intended for Patient B. Should have been given ALENDRONATE 70mg once weekly clearly prescribed on Kardex Patient B given correct medication

• Wrong patient given OXYNORM as nurse entered wrong room - patient did not have wristband on but responded positively to patient name.

Right rate?• Patient given FRUSEMIDE over 2-5

hours instead of 6 hours as prescribed. Pump set incorrectly (10mls hourly instead of 4mls/hourly as prescribed. One nurse only checked pump

• 24hr 5FU infusion delivered at 500mls/hr - at least half bag given to patient before noticed

.

Right drug? • SHO prescribed via phone 10 international

units of ACTRAPID Insulin in 50mls of 50% dextrose over 1 hr but sister drew up 50 international units (showed same to JHO who acknowledged as correct) and infused into patient.

• GENTAMICIN 175mg IV prescribed and given 20/1/06 - patient with significant renal impairment Cr >500 on 21/1/06.

Policies and compatibilities?

• VELOSULIN SYRINGE out of date. Protocol - change syringes every 24 hrs. Syringe in question dated 2l/6/06 - today's date 26/06/06

• Patient allergic to penicillin - given TAZOCIN IV in error which was meant for another patient.

Where there is error, Let us bring truth! ( St Francis)

• Critical incident and near miss reporting– Learn from our mistakes

• System errors– Spot procedures that could lead to error

LiabilityEach NHS Acute Division has two forms of liability in Negligence:

• Direct liability, i.e. the employer itself is at fault

• Vicarious liability or indirect liability

The employer will usually only support the employee if they have practiced within local policies and procedures.