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Spilling Pills on the Job: How One Mistake Led to Disciplinary Action


What to Do When You Spill or Drop Pills on the Job

Last week, the Delaware Supreme Court sided with the state’s board of nursing when it disciplined two supervisory nurses in a correctional facility for giving an inmate pills that were dropped on the floor. Nurses tend to be the ones administering medication to patients, but a simple mistake like dropping pills on the floor can have major legal and regulatory implications. The medication in question happened to be Sovaldi, a medication for Hepatitis C, which costs around $1,000 per pill. While administering the medication to an inmate, one of the nurses accidentally tipped over the bottle of Sovaldi and spilled 12 pills on the floor. Because the drug is one of the most expensive on the market, the facility treated it as a controlled substance.

Find out what these nurses did next and why it led to disciplinary action.

Dropping Pills on the Floor

After the pills landed on the floor, the nurses discarded them by putting them in a sharps container. They then consulted with the pharmacist on duty and told them that a refill of the medication would be necessary. Knowing the full cost of the pills, the pharmacist contacted the nursing supervisor and the head physician of the facility for another opinion. The physician called one of the nurses and told them to remove the pills from the sharps container. Working with the health services administrator and the director of nursing, the two nurses shook the container until the 12 pills fell out, landing on a piece of paper towel. Other medical supplies fell out of the container, including syringes, lancets, other pills and diabetic testing strips.

Once the pills were out, the nurses wrapped them in paper towels and showed them to the pharmacist, who used “the eyeball test” to make sure the pills were safe for consumption. The nurses then gave the pills to the inmate without telling them what had happened moments before. In the end, they saw no ill side-effects after giving the inmate the pills.

Allegations of Unprofessional Conduct

Soon after the nurses administered the pills to the inmate, one of them reported the events to the Delaware Division of Professional Regulation, resulting in allegations being brought against the head physician and the two nurses. Yet during the hearing, one of the nurses testified that they were following the orders of the pharmacist, who told them to administer the pills to the inmate.

The officer overseeing the case ruled that the nurses “were obligated to exercise independent judgment”. If they were aware of their obligation to discard the pills, they should have objected to the pharmacist’s demands or taken steps to avoid giving the inmate the pills. The officer ruled that the nurses violated the state’s practice act, placing them on probation for 90 days. The nurses were also required to take courses in pharmacology and nursing ethics.

Appeals and Final Ruling

After the professional regulation hearing, the nurses appealed the board’s decision to the Superior Court of Delaware, who sided with the nurses, citing the fact that no physical harm came to the inmate in question after administering the medication. This decision overruled the one handed down by the state’s board of profession regulation.

The case made it all the way up to the Delaware Supreme Court, who just last week overturned the Superior Court’s ruling. The court ruled that the state’s board of professional regulation made the right decision in disciplining the nurses, regardless of whether the patient experienced physical harm.

What Nurses Can Learn from This Situation

As a nurse, you should always be aware of your state’s nursing rules and regulations. If a supervisor or one of your colleagues asks you to do something you believe may be in violation of the rules, you should object and even report the suggested violation. Nurses are required to dispose of medication that’s been contaminated. Even if each pill costs thousands of dollars, pills that have touched contaminated surfaces shouldn’t be administered to patients.

It’s also important for you to remember that a complaint can be raised against you even if no harm comes to the patient in question. Your colleagues can also report you to your state’s board or nursing if they believe you have violated your profession’s regulations. This may be true even if one of your colleagues was complicit in committing the violation. Finally, if you violate your state’s nursing laws, it’s nearly impossible to put the blame on someone else, even if you were following your supervisor’s orders.

Keep this case in mind as you go about treating your patients. Be careful when administering medication and always follow your state’s nursing rules and regulations.




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