A recently reported case in which a health professional was reprimanded, serves as a timely reminder for members of the importance of being open and honest when an adverse event occurs.
A highly experienced emergency department nurse with an unblemished record made an error that she then sought to cover up. The Nursing and Midwifery Board brought disciplinary proceedings against her alleging seven grounds of professional misconduct, only two of which related to her initial mistake.
Regrettably, five were due to the emergency nurse’s actions following the mistake, which saw her falsify records, give misleading evidence to AHPRA and conspire with co-workers to conceal the mistake.
This led the state’s disciplinary tribunal to take a dim view of her actions: “… the nature and extent of the conduct and the respondent’s attempts to avoid detection amount to serious departure from the standard expected of a nurse of her experience.”
The case highlights how open disclosure and honesty could have averted this series of events from unfolding.
Failure to comply with clinical procedures and policies
The emergency nurse was on duty when she agreed to look after another nurse’s patients during a tea break. One of the duties allocated to her was to administer intravenous morphine to a patient. However, the emergency nurse entered the wrong cubicle and administered morphine to the wrong patient. In breach of the hospital’s policies, she failed to verify the patient’s name before she administered the morphine, and she did not wait for a second nurse to be present during the administration of morphine. Before administering the medication, the emergency nurse filled in the records incorrectly, indicating the dose had been administered, when it had only been drawn up.
Upon returning from her break, the second nurse realised the morphine was being administered to the incorrect patient and stopped the administration. The emergency nurse then compounded the situation by failing to document the error in the patient’s clinical record, report the incident to the treating doctor or hospital management, and complete a Safety Learning System report. She did not inform the patient of the error. Furthermore, she falsified S8 and S4 requisition forms to conceal the wrongful administration and encouraged the second nurse and another co-worker to stay quiet about the error.
The second nurse notified her supervisors which ultimately led to an internal investigation.
The tribunal said the emergency nurse’s initial conduct was compounded by attempting to cover up the error and lying to her employer and AHPRA by failing to admit the extent of her conduct in correspondence and interviews.
The tribunal noted that on the day of the incident, the emergency nurse was dealing with a family crisis which provided an explanation for her conduct, stating, “Nevertheless, the nature and extent of the conduct and the respondent’s attempts to avoid detection, amount to serious departures from the standard expected of a nurse of her experience.”
The tribunal ultimately suspended her registration for nine months. She was also ordered to complete education on the responsibilities and duties in respect to the administration, documentation and management of medicines, including S8 drugs, obligations in honestly dealing with the regulator in an investigation and ethical conduct, and to complete a reflective practice report.
Importance of open disclosure
It is expected that doctors conduct themselves in an ethical manner, including in matters involving investigations into professional conduct.
If you experience an adverse event, you have a responsibility to be open and honest with the patient and your employer or hospital at which you work. You must document the incident in the patient’s medical record and report it in accordance with your practice or hospital’s procedures and policies. As seen in this case, failing to do so can impact your registration and reputation.
The open disclosure discussion is probably one of the most difficult conversations a doctor can have with a patient or a patient’s family.
Open disclosure is not about apportioning blame to yourself or others. Rather, it’s about informing a patient about what has gone wrong, ameliorating any harm to the patient and learning from the experience.
Adverse events or near misses should be responded to following the ACSQHC’s Australian Open Disclosure Framework:
- An apology or expression of regret should include the words "I am sorry” or “We are sorry”.
- A factual explanation of what happened.
- An explanation of the steps being taken to manage the adverse event and prevent recurrence.
All jurisdictions in Australia have ‘apology laws’ which protect statements of apology or regret made after incidents from being used in a legal context.
Like all difficult conversations, it is best to think about what you want to say and how you might say it. Tips for discussions:
- Ensure the patient is suitably fit to understand the information conveyed.
- Take stock of your emotions.
- Think about the patient’s or family’s expectations.
- Consider how they might feel about the information they are being given.
- Prepare yourself for tears, anger, threats, aggression and silence.
- Practice the words you might use.
- For junior doctors, always discuss it with a more experienced doctor beforehand.
When to notify an adverse event to us
In the event of an adverse event, Avant’s Medico-legal Advisory Service (MLAS) is on hand to provide expert advice to help minimise the chance of a complaint or claim occurring. If you are involved in any incident that may lead to a claim or complaint against you, notify the MLAS as soon as possible so we can help you with appropriate action to minimise the chance of a complaint or claim occurring.
When and what you must notify under your policy
Under your Avant Practitioner Indemnity Insurance Policy* you are required to notify us in writing as soon as practicable when a claim is made against you. You must also notify other events such as a civil or criminal action, prosecution, inquiry, inquest, investigation or complaint, judgement, appeal or tax audit brought or made by a registration board, tribunal, complaints unit, criminal court, civil court or coronial court.
- If you are involved in an adverse event, you have a responsibility to be open and honest with the patient and your employer or organisation where you work. Follow the open disclosure process in accordance with the Australian Open Disclosure Framework and your hospital policy.
- Ensure you document any adverse events in the patient’s medical record and report the incident in accordance with your practice or hospital’s policies and procedures.
- It is paramount that doctors conduct themselves in an ethical manner, including in matters involving investigations into professional conduct.
Download our factsheet on ‘Open disclosure: how to say sorry’ or access further guidance on open disclosure through ACSQHC’s range of resources.
If you experience an adverse event or would like more information or advice on the open disclosure process, call our Medico-legal Advisory Service on 1800 128 268 for expert advice, available 24/7 in emergencies.
*IMPORTANT: Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and PDS, which is available at www.avant.org.au or by contacting us on 1800 128 268.