A nursing student witnessed an experienced nurse improperly administering medications at a nursing home. The nurse would pull medications for multiple patients at once and store them in her drawer for later administration, sometimes hours outside the scheduled time. She also gave one patient's medication to another patient regardless of dose. When confronted, the nurse insisted this was an easier way to work. The student practiced proper medication administration according to regulations. Improper administration can harm patients and is unethical. The student should have reported the nurse to administrators in addition to confronting her.

1. University of South Carolina UpstateMary Black School of NursingProfessional Nursing IssuesSBSN 497Nursing Ethical Dilemma Presentation:The Improper Administration/Handling of MedicationsAlisha Holmes, Erin Hunter, Brittany Jukes, Loren McClaflin

3. Nursing Ethical Dilemma“My nursing dilemma occurred when I was training at my job at a local nursing home as an LPN. The nurse training me would pull medications for a patient and place them in her drawer to be given out hours later. This gave her more time to either talk or do nothing. She also gave medications hours prior to the scheduled time to save herself from constantly walking into the room. Another thing I noticed was that she signed off on treatments that were not given and used other patients medications if her patient did not have their medication regardless of the dose. I told her that this was wrong, but she insisted that this was an easier way to give medications and not be on the floor all night. She stated that there was a DHEC way to do things and an everyday way to do things. Needless to say I practice the DHEC way and not her way.” - Alisha Holmes

5. Identification and BackgroundMedical errors are not uncommon, and they may cause patient morbidity and mortality and significantly increase health care costs. In 1999, it was estimated that up to 98,000 Americans might have died annually as a result of medical errors. Drug administration errors are significant contributors to this problem.(Llewellyn, 2011)

6. Identification and Background continuedAlthough most errors do not result in major morbidity or death, a significant number can potentially seriously harm patients, e.g. wrong site injections. Accidental administration of vasopressors may be the error with the greatest potential to contribute to morbidity and mortality. In a study, 4 errors (12.2%) were due to the inadvertent administration of adrenaline instead of atropine or fentanyl. Although no adverse consequences were reported, subtle organ damage cannot be excluded. Poor ampoule labeling remains a major cause of substitution errors.(Llewellyn, 2011)

7. Identification and Background continuedPeople treated in hospitals in the United States for illnesses and injuries from taking the wrong medication or dose has increased by 52%, according to the Agency of Healthcare Research and Quality.A recent report indicated a jump in figures between 2004 and 2008 from 1.2 million to 1.9 million.The top categories of medications that people were treated and discharged from emergency departments with were painkillers, antibiotics, tranquillizers, antidepressants, corticosteroids and other hormones.(Wrong Medication or Dose, 2011)

9. Identification and Background continued According to the Drug Enforcement Administration (DEA), nearly 7 million Americans are abusing prescription drugs--more than the combined number of those abusing cocaine, heroin, hallucinogens, ecstasy and inhalants--representing an 80 percent increase since 2000. According to the SAMHSA.gov Web site, substance abuse costs businesses $100 billion annually due to productivity loss, absenteeism and insurance premiums. However, it is surprising to note that prescription drug abuse reaches beyond patients and often affects the very practitioners entrusted with delivering the medication. Healthcare professionals are some of the most common abusers of prescription pharmaceuticals, which correlates with their easy access to the medications during the normal course of their duties.(Vrabel, 2010)

10. Identification and Background continuedDrug diversion can occur in all clinical areas, including: falsification of medication administration documentation, replacement of a vial of a controlled drug (e.g., morphine) with saline, excessive wastage (without actual witnessing), shorting doses of patient medications, substitution of non-controlled drugs, discrepancies between actual vs. system medication counts and intentional miscounts (both re stocking on the floors and the central pharmacy and activities within stores and the vault). One study showed that drug diversion could be as high as 18 percent among nurses. However, diversion goes beyond nurses to include physicians, pharmacists and any other employee involved in handling controlled substances.(Vrabel, 2010)

11. Identification and Background continuedNo hospital is immune to drug diversion, but there are proactive steps that can help detect diversion before it becomes an issue of patient safety. In an effort to meet regulatory compliance and prevent diversion, most hospitals have implemented automated dispensing cabinets (ADCs) to provide physical control and limit authorized access using biometrics and bar coding. More recently, hospitals are increasingly using special software technology for medication surveillance.(Vrabel, 2010)

13. Impact on NursingThe ANA has established Standards of Professional Performance that the nurse must incorporate and use as a guide to their nursing care. Included in these standards is ethics, which must be integrated in all areas of nursing practice. The ANA has also developed a Code of Ethics, which “is a guide for carrying out nursing responsibilities that provide quality nursing care and provides for the ethical obligations of the profession.” The Code of Ethics includes advocacy, responsibility, accountability, and confidentiality, not to mention autonomy, beneficence, nonmaleficence, justice, and fidelity, which are all basic health ethics that nurses should practice by. (Perry & Potter, 2009)

14. Impact on Nursing continued6 Rights to Medication Administration:1. The right medication2. The right dose3. The right client4. The right route5. The right time6. The right documentationWhen a nurse fails to acknowledge the 6 Rights, there are ethical and legal ramifications to consider.(Perry & Potter, 2009); (Good, 2011)

15. Impact on Nursing continuedIf the nurse participates in behavior such as the improper administration/handling of patient medications, he/she does not abide by the Standards of Professional Performance or the Code of Ethics, which not only has an impact on patient safety but also has an impact on the nurse’s employment and/or licensure. The possibility of the nurse diverting drugs is also included in the improper administration/handling of patient medications. All health care providers should be aware of how to detect the behaviors of nurses participating in this behavior, how to report such behavior, and how to avoid such behavior, such as not signing off that the nurse witnessed medications being wasted when in fact they did not.(Perry & Potter, 2009); (Laven, 2006)

17. Impact on Nursing continued“There are two aspects to drugdiversion: (1) the direct and indirect impact on a patient's care if the patient does not receive the medications that his or her physician intended, and (2) the impact on the healthcare worker who develops a pattern of drugdiversion. Hospitals want to keep their patients safe and eliminate the opportunities for employees to divert medications and potentially jeopardize their jobs. Early detection can allow hospitals to correct employee behavior before it becomes necessary to impact their employment.”(Vrabel, 2010)

18. When Healing Hands Harm: Drug Diversion in Vermont (Motion picture)Attorney General Sorrellstated, "Early detection and action preserves the integrity of patient care, removes a source of drugs for the offender, and may be the best chance for the offender to confront his or her addiction." “The film succeeds in emphasizing the value of prevention and detection and encouraging health care providers to seek substance abuse help for themselves or others. The film also succeeds in providing a sharp reminder that drugdiversion is a criminal offense for which offenders suffer criminal consequences, including incarceration and license sanctions.”(Attorney general releases…, 2007)

19. What HappenedAn LPN was training with a nurse, who later became the floor supervisor, and the nurse told the LPN that the easiest way to administer medication was to compile all of the medication together at one time instead of giving it at the time when it was scheduled to be given. She also stated that if there were patients that were alert and oriented, the medication could be pulled early and placed inside the locked cart until it was time to administer the medication. Since most of the patients had some type of dementia, they just took the medication when it was presented to them. This violated one of the six rights of medication administration: the right time. Since some of the medication was delivered at the wrong time, pain and certain chronic diseases may have not been managed as effectively as they should have been.(Perry & Potter, 2009)

21. What Should Have HappenedWhat should have happened was the nurse should have administered the medication at the right time (give or take an hour per institution protocol) because there can be therapeutic repercussions for not administering the medication at the correct time. The doctor prescribed the medication at the proper intervals to maximize efficiency. If this is not maintained, the patient could have adverse side effects, or worse, they may become resistant to the medication and may have to change their medication regimen altogether. (Perry & Potter, 2009)

22. In the ethical situation described, the nurse administering the medication violated the 6 Rights to Medication Administration by not giving the meds at the right time, giving one patient’s meds to another patient regardless of the dose, and also by signing off on treatments that were not given(documentation).The LPN acted as a patient advocate and did the responsible thing by confronting the nurse about her actions, as outlined by the Code of Ethics.One additional step the LPN could have taken was to report the incident to the immediate supervisor.

24. Summary and ConclusionAccording to the CDC, adverse drug events can add 8-12 days to the length of hospitalization and account for 770,000 injuries and deaths each year.Medication errors and intentional diversion are becoming increasingly widespread and a serious problem affecting our industry, our jobs, and our patients’ care.As new nurses, we at some point may be witnesses to the mishandling of patient meds, and must be prepared to react professionally, ethically, and morally to those issues stemming from error and criminal intent alike.

25. Summary and Conclusion continuedAn ethical dilemma can present a very real intra-personal conflict between the principles of nonmaleficence and beneficence towards our patients and our profession, and the impact that reporting the situation will have on our co-worker and possibly friend.We must remain mindful of the fact that the person acting in error may have acted willfully, and therefore already understands the consequences of their actions.

26. Alternatively, if the error was made without intent, a learning opportunity does exist.In either situation, it is our responsibility to immediately report the occurrence to the direct supervisor so that education or corrective actions may occur.

27. Summary and Conclusion continuedLaws have been enacted to protect the welfare of citizens and our patients, and provide a mechanism to enforce compliance.

28. The ANA has developed our code of ethics to guide us in the delivery of care practice that provides a framework for ethical decision-making.

29. The “6 Rights” takes the guesswork out of the process of medication administration. Summary and Conclusion continuedWhen faced with any ethical dilemma, one more simple test can lead us to the right decision: ask yourself…“If this situation were to be printed on the front page of tomorrow’s newspaper, what would you want the article to say you did?”

30. Remember:If you fail to report the act, then you, too, are a part of the problem!