DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Monica Seawright, RPN Chairperson Denise Dietrich, RPN Member Karen Breen-Reid, RN Member David Bishop, Public Member Brian Stewart, Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO (Anil Kapoor for College of Nurses of Ontario)

• and -

[THE MEMBER], Registration No. [ ] (No representation for The Member)

Heard: February 7, 2006

DECISION AND REASONS

This matter came on for hearing before a panel of the Discipline Committee on February 7, 2006 at the College of Nurses of Ontario at Toronto.

The Allegations

The allegations against [the member] as stated in the Amended Notice of Hearing dated January 16, 2006 (Exhibit #1), were as follows:

1. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c.32, as amended, and defined in subsection 1(1) of the Ontario Regulations 799/93. in that while employed at [the facility] you failed to maintain the standards of the profession, in that:

a) On or about August 17, 2003 at 0200 you administered a dosage of M.O.S. in the amount of 25mg M.O.S. concentrate to [the client, who] had been ordered 5 mg Q2H prn;

b) On or about August 17, 2003 at 0415 you administered a dosage of M.O.S. in the amount of 25mg M.O.S. concentrate to [the client, who] had been ordered 5 mg Q2H prn.

Member’s Plea

[ ] (The “Member”) admitted the allegations set out in the Amended Notice of Hearing. The panel received a written plea inquiry (Exhibit #2) and also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

Agreed Statement of Facts

Counsel for College of Nurses of Ontario (the “College”) advised the panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts (Exhibit #3) which provided as follows:

THE MEMBER

1. [ ], (“the Member”) has been registered [ ] with the College of Nurses of Ontario since 1960. She was employed from 2002 until April 2005 with [an agency]. The Member [] is no longer nursing and does not intend to return to the practice of nursing.

2. [The facility] is a 140 bed long-term care facility that provides medical, supportive and palliative care to residents. The Member was assigned to work at [the facility] in August 2003.

EVENTS OF AUGUST 17, 2003

3. On August 17, 2003, the Member worked her first night shift [on a wing] on the third floor of [the facility].

4. One of the residents, [the client], had been prescribed liquid Morphine concentrate (50 mg/ml) 5mg to be administered sub-lingually q2h prn. [The client] was 87 years old and had been a resident at [the facility] since April 11, 2003. [The client’s] condition had deteriorated to the point that [the client] was no longer responding to verbal stimuli. [The client] was receiving palliative care.

5. The evening shift nurse, [ ], explained to the Member that [the client] was to receive a small quantity of morphine because the medication was very concentrated. [The evening shift nurse] demonstrated to the Member with a tuberculin syringe how much morphine to administer to [the client].

6. If [the evening shift nurse] were to testify, she would say that the Member kept interrupting her and telling her repeatedly that [the member] already understood how much medication to administer to [the client].

7. [The client’s child] requested that pain medication be administered to [the client]. At approximately 02:00, the Member asked [Nurse B], who was working in the [ ] Wing of the facility, to attend at [the wing] to double check and co-sign for a dosage of morphine for [the client].

8. In the medication room on [the wing], the Member drew up 0.5 ml of the Morphine concentrate, which [the member] intended to administer to [the client]. [Nurse B] observed the Member draw up the morphine.

9. The Narcotic Control Record used to track the administration of M.O.S. concentrate on the unit clearly indicated that the concentration level of the drug was 50 mg/ml. The Narcotic Control Record also advised that the dose of the drug had to be checked with another RN or RPN.

10. The Member and [Nurse B] had a discussion regarding the calculation of the proper dosage. [Nurse B] co-signed for the 25 mg (0.5 ml) dose that the Member had prepared. That dose was then administered to [the client].

11. If [Nurse B] were to testify, she would say that she told the Member that the amount of morphine that the Member drew up was incorrect and that the Member disagreed. [Nurse B] co-signed for the dose despite her concern.

12. At approximately 04:15, the Member again asked [Nurse B] to co-check and sign for another dose of morphine for [the client]. Once again, the Member and [Nurse B] had a discussion regarding the calculation of the proper dosage. [Nurse B] co-signed for the 25 mg (0.5 ml) dose that the Member had prepared. That dose was then administered to [the client].

13. If [Nurse B] were to testify, she would say that she again told the Member that the amount of morphine that the Member drew up was incorrect and that the Member disagreed. [Nurse B] co-signed for the dose despite her concern.

14. [Nurse B] called the Member after the 04:15 dose had been administered to advise her that she thought the dosage was incorrect. According to the Member, this was the first time that [Nurse B] questioned the dosage of morphine.

15. The Member did not call for assistance to discuss the dosage of morphine to be administered to [the client], despite the fact that an On-Call Manager was available to deal with such issues. The on-call schedule is posted where staff can read it.

16. At approximately 06:50, the Member reported to the oncoming nurse, [Nurse C], that she believed that she might have administered the wrong dose of morphine to [the client]. [Nurse C] verified with the Member how much morphine had been administered to [the client] and confirmed that the 25mg (0.5 ml) dose was incorrect. [Nurse C] immediately contacted a physician to report the error and also advised the resident’s family of the mistake. Both an Unusual Occurrence Report for the Ministry of Health and an Incident Report for the facility were completed.

17. [The client] died at approximately 08:15. The coroner, who was called to complete the Certificate of Death, noted that the Morphine overdose was a contributing, but not primary, cause of death.

ADMISSIONS

18. The Member acknowledges that she committed an act or acts of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c.32, as amended, and defined in subsection 1(1) of the Ontario Regulations 799/93. in that while employed at [the facility] she failed to maintain the standards of the profession, in that:

a. On or about August 17, 2003 at 02:00 she administered a dosage of M.O.S. in the amount of 25mg M.O.S. concentrate to [the client] when she had been ordered 5 mg Q2H prn;

b. On or about August 17, 2003 at 04:15 she administered a dosage of M.O.S. in the amount of 25mg M.O.S. concentrate to [the client] when she had been ordered 5 mg Q2H prn.

Decision

The panel considered the Agreed Statement of Facts (ASF) and finds that the facts support a finding of professional misconduct and, in particular, finds that the Member committed an act of professional misconduct as alleged in paragraph 1 of the Amended Notice of Hearing.

Reasons for Decision

The panel deliberated and after due consideration of all the facts and the member’s admission to the allegations, unanimously accepted the ASF as presented, which substantiated the findings of professional misconduct.

Penalty

Counsel for the College advised the panel that a Joint Submission as to Penalty had been agreed upon. The Joint Submission as to Penalty (Exhibit #4) invited the panel to make an order requiring the Member to appear before the panel to be reprimanded at a date to be arranged but in any event within three months of the date of the order. Importantly, the Joint Submission as to Penalty took into account an Undertaking entered into by the Member, which is attached as Appendix A to the panel’s decision and reasons.

Counsel for the College submitted that the penalty is appropriate given that the Member admitted the allegations and willing to cooperate with the College. The penalty provides for specific deterrence through the oral reprimand and general deterrence as it demonstrates that medication errors are taken seriously. Public safety is addressed in that if the Member chooses to administer medications to clients in the future, she will be required to provide evidence of successful completion of a Medication Course approved by the Director of Investigations and Hearings.

Penalty Decision

The panel accepts the Joint Submission as to Penalty (Exhibit #4) with the amendment to the Undertaking (Appendix A, see attached) to omit the word “narcotic” and substitute for it the word “medications” so that the Member is prohibited from administering any medications until successful completion of a medication administration course that has been approved by the Director of Investigations and Hearings. The panel accordingly orders the Member to appear before the panel to be reprimanded at a date to be arranged but in any event within three months of the date of the order.

The panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts, the Undertaking and the proposed penalty, has accepted responsibility for her actions and has avoided unnecessary expense to the College. The panel amended the Undertaking to include administration of all medications. In doing so, the panel recognized that there are risks associated with inappropriate dosage of all medications, not just narcotics.

I, Monica Seawright, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel as listed below:

Chairperson Date

Panel Members: David Bishop, Public Member Brian Stewart, Public Member Denise Dietrich, RPN Karen Breen-Reid, RN

Appendix A

UNDERTAKING

WHEREAS the Executive Committee of the College of Nurses of Ontario (the “College”) referred specified allegations of professional misconduct concerning me to the Discipline Committee of the College on May 26, 2004;

AND IN CONSIDERATION of the College entering into an Agreed Statement of Facts and Joint Submission on Penalty dated October 5, 2005;

I, [The Member], hereby undertake to:

1. refrain from administering medications in any nursing or health care setting until such time as I submit proof in writing to the Director of Investigations and Hearings for the College (the “Director”) that I have successfully completed a Medication Administration Course that has been approved by the Director;

2. provide a copy of this Undertaking to any employer in the health care sector that I currently have or may have in the future.

I HEREBY ACKNOWLEDGE THAT:

1. A failure to meet the terms of this Undertaking could result in the Executive Committee referring allegations of professional misconduct to the Discipline Committee of the College.

2. I fully understand the terms of this Undertaking.

3. I am signing this Undertaking voluntarily and without compulsion or duress.

4. The College of Nurses of Ontario has strongly urged me to obtain independent legal advice prior to signing this Undertaking and that I have had an adequate opportunity to do so.

Dated this day of October, 2005.

[The Member]

Witness