Exposing poor care

Published: 30 August 2011

Agyness Daylan witnessed a shocking drug error that was to have a lasting impact on her nursing career. Her subsequent actions led her to win the 2011 Nursing Standard student award. This is her story

In April 2005 I was involved in an incident that was to change the course of my training and my nursing practice. It happened on my first hospital placement. I remember being extremely nervous as the ward was a highly specialised unit caring for very sick patients.

A week into my placement I was allocated to work with one of the staff nurses. I still found the ward daunting but I was enjoying the learning opportunities available to me.

On one occasion the staff nurse and I went to the preparation room as a patient was due her antibiotics. Together we drew up the Tozacin and saline flush in labelled syringes. With the syringes and prescription chart we went to the patient and introduced ourselves. The nurse accessed the patient’s central line and started to give her the medication. Half way through the procedure the patient asked which drug she was being given. The nurse stopped what she was doing as she realised she was giving the wrong drug to the wrong patient. She had failed to check the patient’s identification band or allergy band.
In an attempt to rectify her mistake, the nurse took a syringe and withdrew 20mls of blood from the central line. She asked me to find a 10ml syringe and when I returned with the syringe she withdrew another 10mls. I later found out that she had returned to the patient’s room and asked her not to tell anyone about the incident. Thankfully, the patient suffered no side effects from the medication, despite also being allergic to Tazocin.

I went on my lunch break, feeling uneasy about the whole experience. When I returned I spoke to the ward manager about what had happened. The nurse had failed to report the incident at all. The case went to the Nursing and Midwifery Council (NMC) and as the main witness I had to give evidence against her. It took three years to close the case. The nurse was struck off the register.

The incident affected my confidence on placements and nine months later I gave up my nurse training. Looking back, I feel anger towards the nurse, not just for her original error but for trying to influence the patient and failing to report the incident. Most of all, I am angry that at the end of this patient’s life she had the unnecessary worry of dealing with solicitors.

When I was giving evidence against the nurse at the NMC, her solicitor said to me: "How can you, as a failed student nurse, question a qualified nurse’s practice?"  I may have been a failure in his eyes, but I have restarted my nurse training and now, half way through my second year, I will never be afraid of questioning any health care professional’s practice again. I have learnt the importance of safe drug administration the hard way and it is a lesson I will never forget.

Please note

This article was first published in Nursing Standard 25, 35, 29 in the name of Joanne Tonkin. Joanne has since changed her name to Agyness Daylan. The photo was taken by Tim George.