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

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.

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.

• You, and you alone, are accountable for your own practice, in spite of potential negative employer reaction to you doing so, as I discussed in this blog post: Is a nurse’s gender and training equally important when treating a victim of sexual assault?

• 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.

Take these courses on prescription management:

Effective Pain Management is More Than Just a Number
(1 contact hr)
Pain Management is a multifaceted challenge. We use pain scales to try to understand how another person may feel or describe pain. This webinar will begin with an introduction to the importance of appropriately  assessing acute and chronic pain as patients experience it as well as the importance of assessing the effect of pain on function. The differences between medication tolerance, dependency, pseudoaddiction, and substance use disorder will be explored. Are opioids always the answer? Are complementary pain therapies just “nice to try” interventions or underappreciated effective remedies? Join an interesting discussion about managing pain with an overview of a multimodal approach with pharmacologic and nonpharmacologic interventions which will help to answer those questions.

Adverse Drug Events
(1 contact hr)
In recent years, the authority to administer medications has expanded to several healthcare disciplines, such as emergency medical services and respiratory therapy. The responsibility of all healthcare professionals with such authority extends far beyond adhering to passing out the correct medication, as virtually all medicines have the capacity to cause adverse effects. The risk of an adverse drug reaction or event rises exponentially with the number of drugs used, in part because polypharmacy reflects the presence of many diseases and provides opportunity for drug-disease and drug-drug interactions. Tools exist to help healthcare professionals minimize the risk for adverse drug events for patients in their care.

Interprofessional Guide to Pain Management
(6 contact hrs)
Pain is experienced by almost all patients regardless of age or sex. Virtually all health professionals help patients who are experiencing pain, and physicians, nurses, therapists, psychologists, pharmacists and social workers can specialize in pain management. Thus, no single discipline completely understands pain, and how or why it manifests in individual patients. To provide comprehensive team-based care, professionals must understand the limits of their own expertise, while gaining insight from and an appreciation for that of other disciplines. This requires health professionals to collaborate to better assess, understand and manage patients with complex pain. By working together for the common goal of developing an effective, safe, comprehensive patient-centered treatment plan, patients with pain who don’t respond to usual treatments can have more positive outcomes.