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 Last modified June 15, 2004  

Case Study

Drawing upon actual reports received by the College, Case Study is an educational tool to assist you in understanding the types of practice issues reviewed by CNO’s Executive, Complaints and/or Discipline Committees and how they render decisions. Case Study consists of a scenario and a series of questions for consideration. These questions highlight some of the matters that committee members had to consider before making their decision. Use these questions to form your own opinion about the case before turning to the Panel’s decision.

Note: Each Case Study is based on a composite of a number of reports to the Complaints Committee. The names, locations and identifying circumstances have been changed to protect the identity of those involved.

SCENARIO: Attempting to hide a medication error

The College received a complaint from a hospital director about a nurse, Beth, who had been suspended following an incident during which she attempted to cover up what she thought was a medication error.

On the day of the incident, Beth and a colleague completed a count of a narcotic drug and found the count was correct. A few hours later, Beth and another nurse did a second narcotic count but this time found that the drug was short one pill.

The director was notified of the incident the next day and made inquiries into the missing pill. About a week later, Beth responded, saying that she could explain why a pill had gone missing.

In the letter of complaint to the College, the director stated that at the time of the incident only one client was prescribed the narcotic drug. Beth told the director that on the morning of the incident she had given the client the pill as prescribed, but had failed to sign all records according to procedure. Later that morning, Beth gave the client his second pill and noticed that she had not signed for the earlier dose. She began to wonder if she had given the first pill. She decided that since her name was not on the MARS, she must not have given the pill. To prevent her error from being discovered, Beth threw away one of the pills thinking this would ensure that the drug count matched the records.

However, when Beth returned to the client later that day to give him a third pill, she noticed that she had made a mistake with the first dose. She had signed for the first dose on the Individual Narcotic Record, which confirmed to her that she actually had given the first pill and had just failed to sign the MARS. This meant that a pill had been lost needlessly, and the count would be out by one.

In her submission to the Complaints Committee, Beth took full responsibility for her actions and admitted that the incident, as outlined in the director’s complaint, was correct.

Since Beth also indicated that she felt a great deal of stress because of the situation, the director decided it was unsafe for her to continue to practise and suspended her for a short time. Before she could return to her job, Beth would have to participate in a re-entry plan developed by the facility.

Committee’s Views

In this case, the Complaints Committee had serious concerns about the member’s medication administration and documentation practices, as well as her attempts to cover up her actions. The committee was impressed that Beth took full responsibility for her actions, and believed that she had learned from the experience.

Questions considered by the Complaints Committee

What are the main practice issues that Beth needs to address, and what resources does the College have to assist her?

Has Beth learned from this experience?

Should Beth’s taking responsibility for the incident affect the Committee’s course of action?

The committee issued Beth a Letter of Caution: a non-disciplinary warning that outlines the committee’s concerns about a nurse’s practice that came to light during the investigation. Letters of Caution serve an educational purpose with a view to impressing upon members the importance of taking steps to improve conduct or practice.

In the letter, the committee reminded Beth that ethical nursing care includes respecting truthfulness and ensuring that resources are handled responsibly. A nurse who attempts to cover up even a perceived medical error is not upholding ethical standards. The letter also cautioned that proper documentation that follows the principles set out in the College’s practice standards is integral to safe and effective nursing practice. If Beth had come forward at the time of the incident, the complaint to the College may have been avoided.

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