Australian Health Practitioner Regulation Agency - Panel hearing summary 2022.0904
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Panel hearing summary 2022.0904

Decision of the Nursing and Midwifery Board of Australia

Performance and professional standards panel 

Jurisdiction: Victoria
Date of Decision: 18 May 2021

Classification of Notification

Pharmacy / Medication - Inappropriate administration and Inaccurate transcription


The Board referred allegations that the Practitioner had twice administered oral form of hydromorphone through subcutaneous syringe pump to the same patient during a shift for which he was the nurse in charge.

The medication paperwork was filled out incorrectly with the schedule medicines drug book clearly showing nil injectable form hydromorphone was available during the Practitioner's shift. The Practitioner also filled out the patient's medication chart with having dispensed oral form of the drug (orally). It was also alleged that the Practitioner had behaved in an unprofessional manner towards two colleagues (a junior RN and an experienced EN) who co-signed for the medication and who pressed the Practitioner on the route of administration. During the health service's internal investigation the Practitioner denied the mistake and accused his colleagues of lying; in an initial response to Ahpra the Practitioner stated he had forgotten to document the oral form as discarded and maintained he correctly administered the right meditation subcutaneously.

By the time of the panel hearing the Practitioner admitted making the mistake and revealed that he was unaware oral form of hydromorphone was not approved for injection. The Practitioner denied behaving in an intimidating or aggressive nature towards colleagues but conceded he should have taken the EN's (in particular) questioning into consideration. Prior to the hearing the Practitioner had completed a two day in person medication administration course.

The Panel determined that the Practitioner’s performance demonstrated a significant deficit in knowledge given his length of experience and training as both an EN and RN. It determined a reprimand was appropriate and imposed monthly mentoring on the importance of demonstrating leadership and respect for colleagues.

Page reviewed 7/06/2023