Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: A corporal who qualified two years ago has noted that, on a few occasions when administering medication, the captain who is a qualified nurse did not check the patient’s drug card and their identity. What should the corporal do?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers medicine management, the ethics and law regarding the safe administration of medication to the patient, clinical competencies and maintaining competence i.e. fitness to practice and possible harm to a patient if they were given the incorrect medication and were identified as another patient.  In a military setting it also covers military rank structure with a lower rank observing sub-standard care by a higher rank and how they should deal with such a circumstance.

Step 2 – ANALYSE

Patient: two principles of Beneficence and non-maleficence apply. This raises concerns about clinical competence. The patient has the right to receive care from a safe practitioner and not one that potentially could put their health and well-being at risk from harm due to a medication and identification error. The Captain has exhibited unsafe practice to their patient.

Clinical: it seems difficult to understand why a qualified nurse irrespective of rank fails to check the patient drug chart and their identity prior to administering any medication. 

Legal: The International Council of Nurses Code of Ethics is at: ICN_Code-of-Ethics_EN_Web.pdf

At section 1.9 it states, ‘Nurses facilitate a culture of safety in health care environments, recognising and addressing threats to people and safe care in health practices, services and settings.’. All healthcare regulators code of practice, which are enshrined in legal statutes say that their primary function is the protection of the patient. This includes good and safe practice when administering medications and adhering to the following principles:

1. Make patient safety the first priority and raise concerns if the service or system they are working in does not have adequate patient safeguards including appropriate identity and verification checks.
2. Understand why patient identification is important especially with vulnerable patients and to take appropriate steps to protect them.
3. To avoid medication errors good practice involves ensuring medication is given to the right patient, the right drug, the right does, the right route and at the right time

In this international ethics code, it also states that nurses (this will apply to all healthcare professional) must also be fit to practice and have the skills, knowledge and competence to practice safely.

As an example of national UK guidance, the UK regulator, the Nursing Midwifery Council has a standards of proficiency document named ‘Future nurse: Standards of proficiency for registered nurses: This can be found at:  future-nurse-proficiencies.pdf (nmc.org.uk) At section 11, it explains the necessary standards for best practice in the administration of medicines.

Some registered nurses have undergone extra training to be able to prescribe medication. The NMC have adopted the Royal Pharmaceutical Society’s Competency Frameworks for all Prescribers found here prescribing-competency-framework.pdf (rpharms.com)

Societal/Military: the employer (adjutant) has the right to know about the fitness for work of his employees (this includes clinical competence) and also has a duty to provide welfare support to military personnel. Through vicarious liability, the employer also has a duty of care not to harm to patients that their healthcare professionals treat. The employer should act first to deal with concerns about a registrant’s fitness to practice, unless the risk to patients or the public is so serious that they need to take immediate action. In this case, it could be not allowing the Captain to administer any medication until an investigation and or risk assessment as to their clinical competence has been carried out followed by some re-training (if necessary) and assessment to ascertain they are safe in medicine administration.  Alternatively, it could be that the employer believes they have reached a point where no further support could be provided and the issue is so serious it warrants referral of the Captain to their regulator. They could believe the Captain’s practice is impaired and there is possible professional misconduct.  Conversely, before any referral they may wish to consider if the Captain has shown insight and willingness to rectify their clinicals concerns as to why they failed to check the patient’s drug card and their identity.

This scenario also raises the issues about why the Corporal has not previously disclosed and reported the Captain’s practice earlier. 

As an example of national guidance, the United Kingdom’s document titled ‘Future nurse: Standard of proficiency for registered nurses at future-nurse-proficiencies.pdf (nmc.org.uk) will be particularly helpful. In Australia, the Nursing and Midwifery Board of Australia use the Registered Nurse Standards for Practice at Nursing and Midwifery Board of Australia - Registered nurse standards for practice (nursingmidwiferyboard.gov.au)

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

This scenario balances military rank with professional clinical practice. There should invoke discussion about the dual loyalty of clinical professionalism and military obligations.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

The Adjutant should be given factual information regarding the immediate implications of the Captain’s fitness to practice. For patient safety and the reputation of the employer it would be good practice to prevent the Captain from administering any medication until their actions are investigated and a discussion with the Captain has taken place with a senior nursing colleague of a higher rank. 

References:

International Council of Nurses (Revised 2021), The ICN Code of Ethics for Nurses at Code. Available at ICN_Code-of-Ethics_EN_Web_0_0.pdf; accessed 24 August 2023

Nursing Midwifery Council: Future nurse: Standards of proficiency for registered nurses. Available at future-nurse-proficiencies.pdf (nmc.org.uk); accessed 24 August 2023

Nursing and Midwifery Board of Australia. Available at https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx; accessed 24 August 2023

Contributor - Lt Col Janet Kelly VR RGN RM DIpHSM MA (HRM) LLB (Hons) PGHCE PhD. Senior Lecturer in Midwifery, Healthcare Law & Ethics; University of Hull. Chair for the Nursing Midwifery Council's Fitness to Practise Conduct and Competence Committees (2013 to 2021). She has served as a commissioned officer in Queen Alexandra's Royal Army Nursing Corps both as a regular and reservist for over 30 years and is now at the rank of Lieutenant Colonel.