Court rules with board of nursing on spilled pills case against nurses

By | 2019-03-12T20:51:58-04:00 March 13th, 2019|30 Comments

Two supervisory nurses in a correctional facility were counting an expensive drug used for Hepatitis C, Sovaldi, for an inmate.

Because the drug was so expensive, the facility required that it be treated as a controlled substance and pills were counted daily.

While doing so, one of them accidentally tipped over the bottle and 12 of the pills fell to the floor. Since the pills came in contact with the floor, the nurses believed they should be discarded. The pills were picked up the from the floor and they disposed of them in the sharps container.

The nurses then informed the pharmacist on duty that a refill of the medication would be necessary.

Due to the high cost of the pills, the pharmacist immediately contacted their supervisor, who in turn contacted the head physician of the facility responsible for patient care. The physician then called one of the nurses and told her to remove the pills from the sharps container.

With the help of the facility’s health services administrator and the director of nursing, the two nurses laid a paper towel on a table, unlocked the container and shook it until the 12 pills fell on the paper towel. Along with the pills, syringes, lancets and diabetic testing strips tumbled out as well.

Once the pills were out, other medical waste was still in the container, but the group did not explore what that waste was.

The two nurses then wrapped the pills in a paper towel and took them to their office, where the on-duty pharmacist and the nurses viewed the pills. The pharmacist thought the pills looked fine and this “eyeball test” became their standard of practice for the state of the pills.

The pills were later given to the inmate with no ill effects and without any knowledge of what had happened to the pills.

However, when one of the two supervisory nurses involved with the disposal of the pills heard they had been given to the inmate, she contacted the state’s Division of Professional Regulation.

Professional disciplinary proceedings initiated

Allegations of unprofessional conduct were brought against the two nurses (along with the head physician).

During the administrative hearing, the nurses testified it was the pharmacist who was the expert on whether the pills could be administered to the inmate and they, therefore, were following his directions.

The nurses testified they were aware of the nursing standard of practice not to administer medications that were spilled or contaminated by falling to the floor. In addition, they both knew of the facility standard of administering spilled medication and to place non-controlled medications into a trash can or sharps container.

The hearing officer ruled the nurses were under orders by the physician and pharmacist to place the pills back into its container and, therefore, were not easily able to disobey that directive.opioid

Even so, the hearing officer determined the nurses “were obligated to exercise independent judgment” in their nursing practice and, therefore, ruled they should have “objected to what was happening or taken steps to avoid it.”

As a result, the hearing officer held the nurses violated the definition of professional conduct in the state practice act and also violated the rule requiring nurses to take appropriate action to safeguard their patients.

The nurses were placed on probation for 90 days and were required to take courses in pharmacology and nursing ethics.

Nurses appeal hearing officer’s ruling

The nurses’ appeal to the Superior Court of Delaware resulted in an interesting decision. Because there was no evidence of harm to the inmate during the administrative hearing, the court ruled in favor of the nurses, nullified their discipline and held that the state must prove the nurses’ conduct put the inmate at risk.

Board of Nursing appeals Superior Court ruling

The Delaware Supreme Court reversed the Superior Court’s ruling, holding that the board applied the correct standard of practice to the nurses’ conduct and its decision to discipline them rested on substantial evidence.

Why this case is important for your practice

This case stands for many principles that affect your nursing practice. The following tips are important to remember whether you’re an RN, LPN or advanced practice nurse:

  • A board of nursing has the authority to discipline nurses based on the nurse practice act and rules.
  • It is almost impossible to try to shift the burden of your professional responsibility to another.
  • Actual harm is not required when there is a violation of the act or rules.
  • Anyone can file a complaint against you, including your own colleagues.
  • Know and comply with your state nurse practice act and its rules.
  • Know and comply with your facility’s policies governing medication administration.
  • You always have a duty to protect your patients from harm or the risk of harm.

Read more about this interesting case, “Delaware Board of Nursing v. Christine Mulry Francis and Angela L. Caldwell,” here.

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About the Author:

Our legal information columnist Nancy J. Brent, MS, JD, RN, concentrates her solo law practice in health law and legal representation, consultation, and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues and has published extensively in the area of law and nursing practice. She brings more than 40 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. 


  1. Greg Ekland March 17, 2019 at 5:12 am - Reply

    Are the pharmacist, physician, or hospital administrators involved facing equitable legal actions or more severe given they ordered the nurses to do this?

    • Edith Brous March 29, 2019 at 11:59 pm - Reply

      Pharmacy and medical boards did not discipline – only nursing.

      • Done September 23, 2019 at 1:00 pm - Reply

        So WRONG! The Nurses tried to do everything right from disposal to reporting the spill and disposal, and reporting it when they found out the medication had been used (which would not have happened if not for the Dr and Pharmacist! I wonder if they thought they were removing the pills to account for them only, NOT to eventually reuse. Now Drs Pharmacists and supervisors will give careless orders under the guise of authority and expertise knowing they won be accountable, and Nurses will be even more afraid to report wrong doings. Its BS like this that cause our nursing shortage. This wasn’t just a 5 rights or noting unsafe dosage written by a Dr., This was pushed by the administrative and Medical hierarchy in charge of local practice policy. I bet if the nurses had refused they would have been fined the cost of the medication, and fired for insubordination or at least gotten a poor eval resulting in loss of promotion and bonus opportunities. And still, the Dr, Pharmacist, or supervisor wouldn’t have had to accept any accountability. I read another case where the nurse refused to give a medication, explained why to the MD, but was the only one sued after the MD then spoke to and directly ordered a Paramedic to give the medication and the patient was hurt.

  2. D. B. March 17, 2019 at 8:05 am - Reply

    That Pharmacist would have had to come give those pills him/herself. There is no telling what was in that sharps container! Disposing of the pills was the right and ethical thing to do in my opinion. Would they have wanted those pills given to their family member or themselves?

  3. GENIFER J JOHNSON DHA MSN RN March 17, 2019 at 11:08 am - Reply

    When I taught pharmacology I spent a great deal of time on legal and ethical issues. I posed a question to the class: “If you received an order for 75 mg of morphine IV push every 4 hours, would you administer the medication?”
    The students would mull it over and the answer was a resounding “Yes!” My next question: “Why?” The usual response was because the medication was identified, the dosage, route, and frequency were all present in the order, so it should be OK. We would follow this with a discussion of autonomy, independent thought, chain of command, patient over employer, etc.
    My purpose was to avoid them making this same kind of “Nursing 101” mistake. We are employed by an institution, but we work for the patient. If we have to stand up for the patient, that is what is required. Operate within the Nurse Practice Act, behave ethically, and you can find another job. You can’t find another license and you can’t eliminate you conscience.

  4. Marie Kassai March 17, 2019 at 1:05 pm - Reply

    What about the risk of the nurse going through a sharps container? This I would think is an OSHA violation.

  5. Edie Brous March 17, 2019 at 3:39 pm - Reply

    Important to note that complaints were also made to the licensing boards about the physicians and the pharmacists but only the nursing board imposed disciplinary action.

    • Elaina C Mahlan March 20, 2019 at 5:24 pm - Reply

      Thank you for sharing Edie. Do you know where I can read more about what happened with the physician and pharmacists?

  6. Kathleen March 17, 2019 at 4:15 pm - Reply

    If the pills are so expensive they should be put into plastic pill packs like a controlled substance would be , such an a tramadol or Norco. Also I get that the nurses were negligent, but what about the pharmacist.

    I would think in that instance I would have told the pharmacist to come and get the sharps and take the middle man i.e. the nurse out of the equation. They did the right thing from the get go. They should have left that buck in the pharmacists desk and let that guy deal with it.

    • Maggie Boleyn March 23, 2019 at 1:53 pm - Reply

      Excellent point!

  7. Beth Stone March 17, 2019 at 6:01 pm - Reply

    JUST SAY NO!!!! The nurses were the only ethical people in this chain of command. Because they were at the bottom of that chain, they were bullied into doing something that goes against every moral fiber in their body. Sadly this happens ALL THE TIME. I can only speculate that they feared they would lose their jobs if they did not comply with their “Leaders”.

  8. Amanda Huffman March 17, 2019 at 6:08 pm - Reply

    What happened with the pharmacist?

  9. Mary L. Grabski March 18, 2019 at 3:04 am - Reply

    Disgusting! Disposed into a “SHARPS CONTAINER”?? Were they SHARP? Call your supervisor FIRST, not last!

  10. Brad March 18, 2019 at 1:09 pm - Reply

    While I believe the story on spilled pills in the prison is important and a valuable learning tool, I think the story does an injustice in telling the story without also highlighting what happened to the Pharmacist and the head physician. Considering the nurses involved were “following orders”, and the nurses probably rightfully believed their jobs were on the line, these two should also be held responsible for what happened.

  11. Joana March 19, 2019 at 3:01 am - Reply

    The nurses” initial action of not giving the medication of “spilled pills” that dropped to the floor was correct! They were contaminated at that point! Not only does proper nursing practice dictate this but common sense does… that a nurse does not administer anything to her/his patient that has been contaminated! That is elementary and what we were taught in nursing school! The nurses properly, per their facilities protocol, “disposed of them in the sharps container”.

    What happened after that is reprehensible and contrary to all ethics and practice!
    Once an object and/or anything else is disposed of in the sharps container that stays there! Sharps containers are to be disposed of and never opened to go through and remove things. This nursing action, by the way, put the nurses and/or anyone else who participated in this action in danger of being contaminated and they will require on-going blood monitoring for HIV, liver disease and God knows what else!! To compound this… to administer these grossly contaminated pills that were on the floor and deposited into a sharps container is beyond belief. The patient was harmed by that action and will require on-going blood monitoring for HIV, liver disease and God knows what else!

    As a nurse I find these actions reprehensible and non-defensible!

    All who participated bear responsibility for their unprofessional actions… nurses, physician, pharmacist! The nurses should never have given the contaminated medication to the patient under any circumstances and should have immediately called their supervisor to intervene and the Director of Nurses as necessary! In-service on proper administration of medication is absolutely necessary for all disciplines involved and sanctions!

    Also the facility should consider changing its policy on the disposing of medications as putting pills in a sharps container! It puts the staff at risk of disease. Pills should be disposed of in a proper “draining system” with two nurses monitoring the procedure and the supervisor as necessary.

    AND… the “cost of the pills” MUST NEVER supercede the Safety of the patient!

    Thank you for this interesting scenario.

    Joana Livoti, R.N.,B.S.,M.S.

  12. Michelle Brown March 19, 2019 at 5:23 am - Reply

    Thanks for following and authoring this important text. I have been fired and disciplined by previous employers for following these rules but do not regret it as those nurses found themselves in court for using poor judgement. As an LVN for 20 years, I won’t let a doctor, pharmacist nor law enforcement officer cause me to practice unethical treatment of my patient, be he or she an inmate, psychiatric, bedbound, infant or otherwise. This is a good learning lesson.

  13. Elaina Mahlan March 20, 2019 at 5:22 pm - Reply

    Where can we read more about the action brought against the physician?

  14. Elaina Mahlan March 20, 2019 at 5:28 pm - Reply

    I feel compelled to ask the question if this would have occurred in hospital setting or only in the correctional system. Is there any hint of a double standard of care here?

  15. Mary Alice Maine March 20, 2019 at 7:43 pm - Reply

    Deflecting comments should not distract from the facts of this described case, which is about nurses making a decision to do something they know should not be done. There are reasons for why they made the decision to retrieve contaminated medications from a sharps container, and reasons they decided to administer contaminated medications to a patient. None of the reasons supercede their obligation to practice nursing with integrity and to provide ethical and safe patient care.

  16. marsha biery-stone March 22, 2019 at 1:39 am - Reply

    I am appalled that anyone would open a sharps container. Let alone remove something from it. As a nurse I would expect the nurse to refuse. When costs outway safety and ethics it is a sad state of affairs.

  17. Noreen, MSN, RN-BC March 22, 2019 at 5:23 pm - Reply

    I do not believe this happened! It`s hype to traumatize people!

  18. Maggie Boleyn March 23, 2019 at 2:00 pm - Reply

    To me, this sounds like someone was itching for some payback in reporting this incident.
    Having said that, putting any pills, let alone an expensive drug, into the sharps container raised a problem for me. Disgusting and not a good way to dispose of drugs.
    I like the comment below–if this drug is so costly, why isn’t it provided in those bubble pack things that are dated. It would keep the drug from being pawed over each shift during the count.
    And, why was felt that the count needed to be implemented? Was someone diverting the drugs beforehand? This whole story sounds a little weird to me.

  19. Dibor Roberts March 31, 2019 at 7:16 pm - Reply

    Dibor Roberts March 31 2019
    To me, this sounds very strange. When the nurse call the Pharmacist, they should have held a meeting with the manager, the Medical Doctor, and the Pharmacist to found out how to reorder the medication and may be held the nurse accountable for pilled the medication in the floor, or make her pay for the medication if they do not have other solution before going to the state board and reporting the act. They should not have retrieved the medication from the biohazard . That is why it is call biohazard. On the other hand what about quality management ? the organization should support the employees to develop quality knowledge and skills to improve their work process. If the medication was very expensive, it should have been placed in a pyxis or a lock unit where you can only be able to remove one pill at a time. Belief in the people who are working to practice safe patient environment , by recognizing the insight and knowledge held by the professional health and allow them to be involve with improvement of their own work . Several people have made mistake in this issue and may be all of us will learn from it.

  20. Rizza April 1, 2019 at 2:59 am - Reply

    “It’s always the nurses fault.” Everyone is always right and nurses are always wrong! God help all nurses!!!

  21. Debi Blank, RN April 1, 2019 at 3:38 pm - Reply

    I find this entire case following the disposal of the spilled pills very suspicious. Up to that point the process worked as it should, even following the policy of contaminated medicine disposal. In any other setting there would be no question of using medicine that hit the floor, knowing as we do how thoroughly the 3 or 5 second rule has been disproven. So do prison inmates have no expectation that medical treatment will reflect best practices? Yes, the medicine was expensive but it had been deemed necessary for the health of the inmate/patient. This incident should have created a meeting of the minds to find a better way to handle expensive medicine in the institution, and not exposing the patient to all manner of possible pathogens.

  22. Nurse eric September 19, 2019 at 5:06 am - Reply

    Nurses get screwed all the time. However, in this case they should have refused!!! As a nurse of 32 years I have refused orders. REMEMBER YOU ARE RESPONSIBLE TO PROTECT YOURSELF. THE BOARD IS NOT YOUR FRIEND, TRUST ME!!!!

  23. Nonkululeko Ngobese September 21, 2019 at 1:40 pm - Reply

    You do not ever, retrieve anything from the sharps container. They should have called the pharmacist when the pills were on the floor. The pair needs training on occ. health and infection control as well. They put their own safety in grave danger. Nurse managers must empower nurses courses so they can assert themselves.

  24. zsazsa parker May 3, 2020 at 4:19 pm - Reply


    • Patrice Stuart May 5, 2020 at 7:44 pm - Reply

      I believe that the nurses should be held accountable for there actions; rather or not the patient were effected by the medication. We are to feel because they are prisoner no harm no shame. That is not right. The nurses was following the Physician and Pharmacist order. What about Moral’s How would they feel if that was a love one? What happened to the Pharmacist and the head physician.

  25. Melinda September 20, 2023 at 9:27 pm - Reply

    Really, Noreen? I’m stunned by your response, and cognitive bias, especially from a nurse with a Master’s Degree. No offense intended. Fact checking case law is quite easy to do even if you do not have a subscription to LEXISNEXIS. Anyone can go to the Delaware Supreme Court to locate the case.

    Additionally, are you aware that your post insults nurses with legal degrees? Especially the author of this article, Nancy J. Brent, MS, JD, RN. What, if any benefit, would she receive by, using your words, “traumatize people?”

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