Legal and Professional Issues

1. IV Medicine Administration Legal and Professional Issues September 2009

2. 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

3. Four Arenas of Accountability To the public To the patient To the employer To the profession

4. New Code launched 1st May 2008 Competency Consent Delegation Code of Conduct

5. Competency • Recognise & work within the limits of your competence • You must have the knowledge & skills for safe & effective practice when working without direct supervision

6. Consent • All individuals capacity to consent is assumed unless there is evidence to the contrary. • No adult can validly give consent for another adult unless legally authorised to do so - Adults with Incapacity Act (2000) • It is not necessary to document consent to routine and low-risk procedures e.g. taking a blood sample. • However, if the procedure is of particular concern to the patient it would be helpful to do so.

7. 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 Delegation

8. 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

9. Law & Nursing • 2 Types of Law: • Criminal Law (Public) • Civil Law (Patient)

10. 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.

11. Misconduct • 686,886 nurses on the register 2008 • Scotland 10% of register but account for only 8% of complaints • 1,487 complaints received 2008  8.4% - Employer 53% - Public 9% • Police 29% • Closed – 35% cases • Referred to conduct & competence committee - 441 (16%) cases

12. NMC • Maladministration of medicines represent 9.9% 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

13. 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

14. 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

15. Conduct & Competency Committee Stages: • Are the facts alleged proved? • Is it misconduct? • What is known about the practitioner’s previous history and in mitigation?

16. Conduct & Competency Committee Outcomes 482 cases heard • Strike name off register (44%) • Caution 1-5 yrs (19%) • No action taken (7%) • Conditions of practise >3yrs (1%) • Suspend registration >1yr (6%)

18. 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.

19. 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 .

20. 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.

21. 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.

22. 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

23. Liability Each 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.