Mr Raymond Cooper, 71, was admitted to SoN Hospital on April 3, 2021, with renal complications, liver and heart failure. He was allocated to room 21. Mr Cooper was prescribed Metformin 500mg BD and Actrapid as per the sliding scale chart. In room 24 was Mr John Cowper. Cowper was an insulin dependant diabetic and required both subcutaneous Novorapid 48 units mane, a drug kept in the fridge in the medication room, and 10 units Lantus subcutaneously mane. There were two nurses present at the bedside when Mr Cooper was mistakenly administered Novorapid 48 units and Lantus 10 units subcutaneously, after which he died nine days later. One of the nurses present was an enrolled nurse – Mr Salmon. Salmon was primarily responsible for the care of both Mr Cooper and Mr Cowper, as well as two other patients in the ward. Salmon, who has since been the subject of an inquiry by AHPRA and the coroner’s court, was adamant that a registered nurse (Ms Bailey), who had accompanied him, had in fact administered the medication to Mr Cooper without calling out the identity numbers first. Salmon also claimed that he did not see the medication being given because he was busy looking at the patient chart. Bailey, who administered the medication, stated that she did in fact call out the patient’s name, date of birth and MRN/URN number. An expert witness told the inquiry that the medication error “shortened” Mr Cooper’s life expectancy and that the dose of insulin would have “flattened him”—as he was a frail elderly patient who had liver impairment. The coroner stated that “it is no coincidence that Mr Cooper’s health dramatically deteriorated in the hours following the administration of the insulin,” finding that the medication error was consistent with a “state of inattention.” The coroner found that “the Enrolled nurse was in the room along with the other nurse; however, it is apparent that had he been concentrating, he would have identified Mr Cooper as the wrong patient, having nursed both Mr Cooper and Mr Cowper that morning.” The coroner further added, “it is consistent with that state of inattention that the enrolled nurse would also have failed to listen carefully to the identification as read out from the wristband.” Question: examine the key legal and ethical aspects of the case study, taking into account the scope of practice of the registered nurse and consideration of safety and quality in medication management practices via national standards.
Mr Raymond Cooper, 71, was admitted to SoN Hospital on April 3, 2021, with renal complications, liver and heart failure. He was allocated to room 21. Mr Cooper was prescribed Metformin 500mg BD and Actrapid as per the sliding scale chart.
In room 24 was Mr John Cowper. Cowper was an insulin dependant diabetic and required both subcutaneous Novorapid 48 units mane, a drug kept in the fridge in the medication room, and 10 units Lantus subcutaneously mane.
There were two nurses present at the bedside when Mr Cooper was mistakenly administered Novorapid 48 units and Lantus 10 units subcutaneously, after which he died nine days later.
One of the nurses present was an enrolled nurse – Mr Salmon. Salmon was primarily responsible for the care of both Mr Cooper and Mr Cowper, as well as two other patients in the ward. Salmon, who has since been the subject of an inquiry by AHPRA and the coroner’s court, was adamant that a registered nurse (Ms Bailey), who had accompanied him, had in fact administered the medication to Mr Cooper without calling out the identity numbers first.
Salmon also claimed that he did not see the medication being given because he was busy looking at the patient chart. Bailey, who administered the medication, stated that she did in fact call out the patient’s name, date of birth and MRN/URN number.
An expert witness told the inquiry that the medication error “shortened” Mr Cooper’s life expectancy and that the dose of insulin would have “flattened him”—as he was a frail elderly patient who had liver impairment.
The coroner stated that “it is no coincidence that Mr Cooper’s health dramatically deteriorated in the hours following the administration of the insulin,” finding that the medication error was consistent with a “state of inattention.” The coroner found that “the Enrolled nurse was in the room along with the other nurse; however, it is apparent that had he been concentrating, he would have identified Mr Cooper as the wrong patient, having nursed both Mr Cooper and Mr Cowper that morning.” The coroner further added, “it is consistent with that state of inattention that the enrolled nurse would also have failed to listen carefully to the identification as read out from the wristband.”
Question: examine the key legal and ethical aspects of the case study, taking into account the scope of practice of the registered nurse and consideration of safety and quality in medication management practices via national standards.
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