Problem
Jones is a Registered Nurse with 30 years' experience- most of this spent in the Intensive Care Unit and Operating Theatre. Jones has an unblemished record in her career, working in a variety of hospitals. Jones was coming to work an afternoon shift in a busy operating theatre, of which she was assigned to work in charge of the Recovery Room. On arrival, she was given handover and found her staffing for 12 beds to have 3 Registered Nurses (which included herself) and 1 Enrolled Nurse. The Recovery room was very busy with a variety of patients coming directly from the Operating Theatre, mostly with orthopaedic and abdominal surgeries. On arrival to the shift, one of the morning staff members (Registered Nurse Mayberry) was called away to deal with a family crisis and had left early. Jones agreed to look after Mayberry's patients, of which there were 2 patients already in the recovery room.
Prior to leaving, Mayberry handed a kidney dish containing a syringe and informed Jones that this was "Morphine IV 5mg for the patient Walter Cunningham in Bed Bay 11".
Jones went alone into Bed Bay 11 and asked the patient if their name was Walter Cunningham. The patient made a grunting sound, which appeared to be answering yes, so Jones proceeded to administer the medication that was in the kidney dish. After administration of the Morphine, Jones looked for the medication chart to sign for the medication given. Jones picked up the chart at the end of the bed and saw that the chart for Bed Bay 11 stated the patient's name as Damien Moses. Jones also noted that Damien Moses had had previously been given a dose of Morphine 2.5mg IV by RN Mayberry 30 minutes before he left. Checking the patients ID band, Jones then realised she had administered the Morphine to the wrong patient.
Jones told the two other registered nurses and the enrolled nurse on duty at the time what had happened but asked them not to report the incident. Initially, they agreed, but the Enrolled Nurse then thought better of it and notified her supervisors which led to the hospital carrying out an internal investigation.
The internal investigation committee established that Jones administered Morphine to the wrong patient and that she did not sign for this medication administration. After this error, another RN on shift (RN Goldie) administered the required analgesia as per the medication chart to Walter Cunningham. Damien Moses was never told of the morphine mix-up at the time. In her defense Jones told the investigation committee that the patient (Damien Moses) was "moaning and obviously needed the pain relief anyway." Jones also stated that Damien Moses had "no ill affects related to this medication administration and therefore she felt the situation did not require further notification."
The internal investigation noted that Ms Jones had a previous unblemished record. A notification was made to AHPRA, and further investigations were ongoing.
i. Identify scope of practice issues that relates to the case study.
ii. Identify the legal aspects of the case with reference to legislation.
iii. Identify the ethical aspects of the case in relation to nursing codes and standards.
iv. Adheres to academic writing principles.