Nurse gave patient 10 times drug dose
A nurse who wrongly administered medication - giving one patient 10 times the amount required - has been ordered to address her failings and must be kept under review for six months.
Michelle Roberts was employed as a registered nurse by St Giles Hospice from September 2012 until her dismissal in November 2013 and last December she started work as a band five staff nurse at Walsall Manor Hospital where she still works, the Nursing and Midwifery Council heard.
Mrs Roberts, who was not present at the recent hearing in London, qualified as a registered nurse in March 2006 and had also worked at the Manor between 2007 and 2012.
A report from the hearing said Mrs Roberts admitted that while working at St Giles Hospice in September 2013 she wrongly administered 150mg of oramorph concentrate - a medicine which is used in relieving severe pain - instead of 15mg of oramorph.
Mrs Roberts then monitored the patient but did not take formal observations or tell a medic or the on-call consultant, a panel heard.
After a morning handover, she told the clinical nurse manager about the error and only updated patient notes after being prompted.
The panel was told that she had failed to follow procedures and was suspended.
An investigation was launched and Mrs Roberts said she had gone to the drugs cupboard and picked up the wrong bottle - concentrated oramorph instead of oramorph.
She said she attempted to fill in a medication error incident form but did not know how and left it until the next morning.
In January this year, Mrs Roberts was asked to assist with an omeprazole infusion for a patient at Manor Hospital.
Omeprazole is used to treat symptoms of gastroesophageal reflux disease and other conditions caused by excess stomach acid.
She did not check the prescription regime and started the infusion of 80mgs for one hour instead of 10 hours as prescribed.
She was unable to log the incident electronically due to an technical issue but later reported the incident to a senior sister and an investigation was launched.
It was found she had failed to follow the correct medicines policy and never told an appropriate medic.
Mrs Roberts was suspended from administering medicines until she completed a study day, workbook and drug assessments.
The report said that she had admitted the failings and the panel were satisfied Mrs Roberts' actions amounted to misconduct.
Neither of the patients came to any harm but were monitored afterwards.
The report said: "The panel concluded that Mrs Roberts' actions put patients A and B at unwarranted risk of harm.
"Mrs Roberts incorrectly administered medication to both patients A and B, and thereafter she failed to take appropriate action to rectify her errors."
She was handed a six month conditions of practice order and must work with a manager to create a plan addressing issues including drug administration and record keeping.
She must also have regular performance reviews.
Peter Holliday, group chief executive of St Giles Hospice, said: "St Giles Hospice is committed to delivering the highest possible standards of care to local people living with cancer and other serious illnesses. In this very exceptional case those standards were not met, and following our own stringent internal procedures a member of our nursing staff was found guilty of misconduct and dismissed. As is appropriate in such circumstances, the case was referred to the Nursing and Midwifery Council, who instigated a Fitness to Practise Hearing."
