Court rules with board of nursing on spilled pills case against nurses

Two supervisory nurses in a correctional facility were counting an expensive drug used for Hepatitis C, Sovaldi, for an inmate.

Because the drug was so expensive, the facility required that it be treated as a controlled substance and pills were counted daily.

While doing so, one of them accidentally tipped over the bottle and 12 of the pills fell to the floor. Since the pills came in contact with the floor, the nurses believed they should be discarded. The pills were picked up the from the floor and they disposed of them in the sharps container.

The nurses then informed the pharmacist on duty that a refill of the medication would be necessary.

Due to the high cost of the pills, the pharmacist immediately contacted their supervisor, who in turn contacted the head physician of the facility responsible for patient care. The physician then called one of the nurses and told her to remove the pills from the sharps container.

With the help of the facility’s health services administrator and the director of nursing, the two nurses laid a paper towel on a table, unlocked the container and shook it until the 12 pills fell on the paper towel. Along with the pills, syringes, lancets and diabetic testing strips tumbled out as well.

Once the pills were out, other medical waste was still in the container, but the group did not explore what that waste was.

The two nurses then wrapped the pills in a paper towel and took them to their office, where the on-duty pharmacist and the nurses viewed the pills. The pharmacist thought the pills looked fine and this “eyeball test” became their standard of practice for the state of the pills.

The pills were later given to the inmate with no ill effects and without any knowledge of what had happened to the pills.

However, when one of the two supervisory nurses involved with the disposal of the pills heard they had been given to the inmate, she contacted the state’s Division of Professional Regulation.

Professional disciplinary proceedings initiated

Allegations of unprofessional conduct were brought against the two nurses (along with the head physician).

During the administrative hearing, the nurses testified it was the pharmacist who was the expert on whether the pills could be administered to the inmate and they, therefore, were following his directions.

The nurses testified they were aware of the nursing standard of practice not to administer medications that were spilled or contaminated by falling to the floor. In addition, they both knew of the facility standard of administering spilled medication and to place non-controlled medications into a trash can or sharps container.

The hearing officer ruled the nurses were under orders by the physician and pharmacist to place the pills back into its container and, therefore, were not easily able to disobey that directive.

Even so, the hearing officer determined the nurses “were obligated to exercise independent judgment” in their nursing practice and, therefore, ruled they should have “objected to what was happening or taken steps to avoid it.”

As a result, the hearing …read more

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