DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO. PANEL: Joanne Furletti, RN Chairperson Denise Dietrich, RPN Member Dennis Curry, RN Member

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1 DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO PANEL: Joanne Furletti, RN Chairperson Denise Dietrich, RPN Member Dennis Curry, RN Member David Bishop Public Member Betty Hill Public Member BETWEEN: COLLEGE OF NURSES OF ONTARIO ) KAREN JONES for ) College of Nurses of Ontario ) - and - ) ) ) INDIRA CHAUHAN ) MARY HART for Registration No ) Indira Chauhan ) ) ) Heard: July 6,7,8,25,26,27 and ) November 14, 15, 16, 17, 2005 DECISION AND REASONS This matter came on for hearing before a panel of the Discipline Committee on July 2, The hearing proceeded as a contested hearing and the panel heard testimony on July 2, 3, 4, 5, 25, 26 and 27, 2005 at the College of Nurses of Ontario ( the College ) at Toronto. The hearing resumed on November 14, 2005 [ ]. Counsel was informed by Joanne Furletti, panel chair on November 14, 2005 that Betty Hill, Public Member, was unable to continue the hearing. Under the Statutory Powers Procedures Act (SPPA), [if] a member of a tribunal who has participated in a hearing becomes unable, for any reason, to complete the hearing or to participate in the decision, the remaining member or members may complete the hearing and give a decision (SPPA 4.4 (1)). This gave the panel the authority to continue with the hearing. Testimony was heard on November 14 & 15, A total of twelve witnesses provided testimony on the aforementioned hearing dates.

2 At the request of both counsels the hearing was adjourned on November 16, 2005 to allow discussion between the two parties. On November 17, 2005 the panel was notified by counsel for the College that an agreement had been reached in regard to the facts of this matter. The Allegations On November 17, 2005 the panel was advised that an Agreed Statement of Facts would be filed. Counsel for the College advised they would be proceeding with the allegations as set out in the Agreed Statement of Facts. These included the following: 1. The Member admits that she has committed acts of professional misconduct in that she failed to maintain the standards of practice of the profession with respect to medication and documentation and in particular: a) On or about July 18, 2002 with respect to [client A] you: i. failed to assess the client s pre and post phlebotomy vital signs; and ii. iii. iv. failed to obtain a blood sample for complete blood count as ordered; and failed to start the phlebotomy procedure in the location of the client s EMLA patch; and failed to document why the phlebotomy procedure was not started in the location of the EMLA patch b) On October 8, 2002, with respect to [client B] she: i. administered the medication Rituxan at the wrong rate; and ii. failed to document the medication error; and iii. failed to document the follow-up regarding the medication error. c) On October 31, 2002 with respect to [client C] she: i. administered the medication Rituxan at the wrong rate; and ii. iii. failed to document the medication error; and failed to take steps to ensure that the client was assessed and treated if necessary following the medication error.

3 d) On December 3, 2002, with respect to [client D] she: i. failed to ensure that the intravenous was running properly; and ii. iii. iv. failed to take all appropriate nursing actions when the intravenous solution came into contact with the client s skin failed to document the incident; and failed to take the steps necessary to ensure that the client was assessed by a health care professional and treated if necessary. e) On December 6, 2002, with respect to [client E] she: i. administered the wrong dose of the medication Doxorubicin to the client; and ii. failed to fully document the medication error and any steps taken to ensure that the client was assessed and treated following the medication error. iii. 2. The Member admits to having committed acts of professional misconduct in that she engaged in conduct or performed an act or acts, relevant to the practice of nursing, that, having regard to all the circumstances, could reasonably be regarded by members as unprofessional and in particular, a) On or about July 18, 2002 with respect to [client A] you: i. failed to assess the client s pre and post phlebotomy vital signs; and ii. failed to obtain a blood sample for complete blood count as ordered; and iii. failed to start the phlebotomy procedure in the location of the client s EMLA patch; and iv. failed to document why the phlebotomy procedure was not started in the location of the EMLA patch

4 b) On October 8, 2002, with respect to [client B] she: i. administered the medication Rituxan at the wrong rate; and ii. failed to document the medication error; and iii. failed to document the follow-up regarding the medication error. c) On October 31, 2002 with respect to [client C] she: i. administered the medication Rituxan at the wrong rate; and ii. failed to document the medication error; and iii. failed to take steps to ensure that the client was assessed and treated if necessary following the medication error. d) On December 3, 2002, with respect to [client D] she: i. failed to ensure that the intravenous was running properly; and ii. failed to take all appropriate nursing actions when the intravenous solution came into contact with the client s skin iii. failed to document the incident; and iv. failed to take the steps necessary to ensure that the client was assessed by a health care professional and treated if necessary. e) On December 6, 2002, with respect to [client E] she: i. administered the wrong dose of the medication Doxorubicin to the client; and ii. failed to fully document the medication error and any steps taken to ensure that the client was assessed and treated following the medication error.

5 Member s Plea Indira Chauhan ( the Member ) admitted the allegations set out in paragraphs numbered 1 and 2 of the Agreed Statement of Facts. The panel started to conduct an oral plea inquiry and given that the Member was unable to continue with the process the counsels submitted a signed plea inquiry as Exhibit # 32. The panel was satisfied that the Member s admission was voluntary, informed and unequivocal. Agreed Statement of Facts THE MEMBER 1. Indira Chauhan ( Member ) graduated [in another country] in 1977 with a four year nursing diploma. She worked in a variety of Intensive Care Units in [other countries] for a number of years. The Member became a member of the College of Nurses of Ontario in 1992 and worked in Intensive Care Unit areas and diagnostic imaging units in different facilities until April 2002, when she was hired as a part-time registered nurse in [the Clinic] at [the Facility]. 2. One of the requirements on the job posting for the Clinic registered nurse position was that the applicant had to have completed a certificate course in oncology nursing and have either recent experience in a chemotherapy clinic or 3 years medical experience with adult cancer patients. Notwithstanding the fact that the Member did not meet these criteria she was offered the position by the Facility with the expectation that she would enrol in and complete a certificate course in oncology nursing. 3. The Member s employment at the Facility was terminated on January 8, The Member does not have a prior discipline history with the College. THE CLINIC 5. In 2002, the Clinic operated as a 5 day a week out-patient clinic. It contained three beds and 17 chairs. It was staffed by a complement of 3-4 registered nurses. Each nurse would generally be assigned five or six clients at the start of each shift and could care for more patients over the course of the shift. Clients attended the Clinic to receive chemotherapy, or to have procedures, such as phlebotomy (removal of a specified amount of blood from the body) and bone marrow aspiration. The Clinic was fast paced. 6. During the period of the Member s employment at the Clinic, a very difficult and tense professional relationship developed between the Member and most of the other Clinic nurses. INCIDENT RE: [CLIENT A]

6 7. The Member was assigned to care for [client A] on July 18, [Client A] had a medical condition that required [client A] to receive frequent phlebotomy treatments at the Clinic for a number of years. [Client A] had a great fear of needles. [Client A] had been ordered EMLA patches, which [were] self administered. The EMLA patch contained a local anaesthetic to numb the area of skin under the patch. Prior to coming to the Clinic, [client A]. would put an EMLA patch over the area where [client A] anticipated receiving a needle. 8. The Clinic protocol regarding phlebotomy required that the nurse take vital signs before and after the treatment. The nurse was also required to take a blood sample for a complete blood count ( CBC ) after the treatment. 9. On July 18, 2002, the Member did not start [client A s] phlebotomy procedure at the EMLA patch site. She did not take pre-and post procedure vital signs, or a CBC as required. She did not document a rationale for not starting [client A s] phlebotomy procedure at the EMLA patch site. INCIDENT RE: [CLIENT B] 10. In 2002, [client B] was receiving chemotherapy treatments at the Clinic for Lymphoma. On October 8, 2002, the Member was assigned to care for [client B] and was responsible for administering her chemotherapy. 11. One of the chemotherapy drugs ordered for [client B] was the medication Rituxan. According to the physician s orders and the Clinic protocol, the Rituxan was to be administered at a rate of 100 mls per hour for 30 minutes and then the rate was to be increased every 30 minutes by a specified amount to a maximum of 400 mls/hour. The Member initiated the client s Rituxan administration at 1150 hours. Another nurse in the Clinic discovered that [client B s] medication was infusing at a rate of 999 mls per hour approximately 10 minutes later. 12. The Member did not document the medication administration error, or any follow-up regarding the medication error. She did not complete an Incident Report in accordance with Facility policy although she was advised to do so by another nurse. Had she testified, the Member would have said she did not recall being advised to complete an Incident Report. INCIDENT RE: [CLIENT C] 13. In 2002, [client C] was receiving chemotherapy treatments at the Clinic for lung cancer. On October 31, 2002, the Member was assigned to care for [client C] and administer her chemotherapy medications. 14. One of the drugs that [client C] was to receive was the medication Rituxan. The client was to receive the Rituxan at a rate of 100 mls per hour for 30 minutes and then the rate was to be increased every 30 minutes by a specified amount to

7 a maximum of 400 mls per hour. The Member initiated [client C s] Rituxan infusion. 15. Sometime later, another nurse in the Clinic discovered that the client s Rituxan was infusing at a rate of 50 mls per hour. 16. The Member did not document the medication administration error, or any follow-up regarding the medication error. She did not complete an Incident Report in accordance with Facility policy. She did not take any steps to ensure there was follow-up regarding the medication error. INCIDENT RE: [CLIENT D] 17. In 2002, [client D] was receiving chemotherapy treatment for [ ] cancer. On December 3, 2002, the Member was assigned to care for [client D] and to administer [ ] chemotherapy. 18. During the course of the chemotherapy administration, [client D s] IV started to leak. Given the concern that the medication being infused could cause tissue damage, the Clinic protocol required that the Member stop the IV, ascertain if the IV was still properly situated in the vein and all connections were tight, and immediately wash the affected area with soap and water. 19. The Member did not follow the protocol. She did not document the fact that the IV had leaked. She did not take any steps to ensure that the client was assessed by a health care professional and treated if necessary. INCIDENT RE: [CLIENT E] 20. In 2002, [client E] was receiving chemotherapy treatment at the Clinic for [ ] cancer. 21. On December 6, 2002, the Member was assigned to care for [client E] and administer [ ] chemotherapy. The Member was also assigned to care for [client F] a client with [ ] cancer, and administer [ ] chemotherapy. [Clients E and F] had similar last names and were assigned to chairs across from each other. [Clients E and F] were ordered to receive some similar medications. 22. The Member administered some of [client F s] medications to [client E], including the chemotherapy agent Doxorubicin. Both clients had been ordered to receive Doxorubicin, but in different dosages. As a result, [client E] received the wrong dose of Doxorubicin. The Member did not fully document the medication error or steps taken to ensure the client was assessed and treated following the medication error. ADMISSIONS

8 23. The Member admits that she has committed acts of professional misconduct in that she failed to maintain the standards of practice of the profession with respect to medication administration and documentation and in particular: (a) On July 18, 2002 with respect to [client A] she: (iv) failed to assess the client s pre and post phlebotomy vital signs; and failed to obtain a blood sample for complete blood count as ordered; and failed to start the phlebotomy procedure in the location of the client s EMLA patch; and failed to document why the phlebotomy procedure was not started in the location of the EMLA patch. (b) On October 8, 2002, with respect to [client B] she: administered the medication Rituxan at the wrong rate; and failed to document the medication error; and failed to document the follow-up regarding the medication error. (c) On October 31, 2002 with respect to [client C] she: administered the medication Rituxan at the wrong rate; and failed to document the medication error; and failed to take steps to ensure that the client was assessed and treated if necessary following the medication error. (d) On December 3, 2002, with respect to [client D] she: (iv) failed to ensure that the intravenous was running properly; and failed to take all appropriate nursing actions when the intravenous solution came into contact with the client s skin; and failed to document the incident; and failed to take the steps necessary to ensure that the client was assessed by a health care professional and treated if necessary. (e) On December 6, 2002, with respect to [client E] she:

9 administered the wrong dose of the medication Doxorubicin to the client; and failed to fully document the medication error and any steps taken to ensure that the client was assessed and treated following the medication error. 24. The Member admits to having committed acts of professional misconduct in that she engaged in conduct or performed an act or acts, relevant to the practice of nursing, that, having regard to all the circumstances, could reasonably be regarded by members as unprofessional, and in particular, (a) On July 18, 2002 with respect to [client A] she: (iv) failed to assess the client s pre and post phlebotomy vital signs; and failed to obtain a blood sample for complete blood count as ordered; and failed to start the phlebotomy procedure in the location of the client s EMLA patch; and failed to document why the phlebotomy procedure was not started in the location of the EMLA patch. (b) On October 8, 2002, with respect to [client B] she: administered the medication Rituxan at the wrong rate; and failed to document the medication error; and failed to document the follow-up regarding the medication error. (c) On October 31, 2002 with respect to [client C] she: administered the medication Rituxan at the wrong rate; and failed to document the medication error; and failed to take steps to ensure that the client was assessed and treated if necessary following the medication error. (d) On December 3, 2002, with respect to [client D] she: failed to ensure that the intravenous was running properly; and failed to take all appropriate nursing actions when the intravenous solution came into contact with the client s skin; and

10 (iv) failed to document the incident; and failed to take the steps necessary to ensure that the client was assessed by a health care professional and treated if necessary. (e) On December 6, 2002, with respect to [client E] she: administered the wrong dose of the medication Doxorubicin to the client; and failed to fully document the medication error and any steps taken to ensure that the client was assessed and treated following the medication error. Decision The panel finds that the Agreed Statement of Facts supports findings that the Member failed to maintain the standards of practice of the profession with respect to medication administration and documentation. As well the panel found that the Member performed an act relevant to the practice of nursing that could reasonably be regarded by members as unprofessional. Reasons for Decision The panel deliberated and found that the evidence in the Agreed Statement of Facts support findings of professional misconduct. In that the Member admits that she has committed acts of professional misconduct in that she failed to maintain the standards of practice of the profession with respect to medication administration and documentation. The Member further admits to having committed acts of professional misconduct in that she engaged in conduct or performed an act or acts, relevant to the practice of nursing, that, having regard to all the circumstances, could reasonably be regarded by members as unprofessional. Penalty Counsel for the College advised the panel that a Joint Submission as to Penalty had been agreed upon. The Joint Submission as to Penalty provides as follows: Joint Submission on Penalty The College of Nurses of Ontario (the College ) and Indira Chauhan (the Member ) jointly submit that, in view of the facts and admissions set out in the Agreed Statement of Facts, the panel of the Discipline Committee should make an Order: 1. Requiring the Member to appear before the panel to be reprimanded; and

11 2. Directing the Executive Director to suspend the Member s certificate of registration for 45 days; and 3. Directing the Executive Director to impose the following terms, conditions, and limitations on the Member s certificate of registration: i. That the Member provide evidence of successful completion of a course or courses in medication administration and documentation that has been approved of by the Director of Investigations and Hearings ( Director ), prior to returning to clinical practice and in any event within 12 months of the date of the panel s decision in this matter; ii. That within 45 days of the date of the panel s decision in this matter, the Member meet with a College Practice Consultant. The Member will provide the Practice Consultant with the results of a Self-Reflective exercise that focuses on the issues of medication administration, documentation and professional responsibility and review with the Practice Consultant the results of the exercise and the College s Standards of Practice, and discuss the issues that arose in this case as they relate to the Member and her practice. The Member will complete a second Self- Reflective exercise regarding medication administration, documentation and professional responsibility and meet again with the Practice Consultant 10 months after the first meeting to review the results of the second exercise. iii. Until the Member has completed 12 months of practice following the date of this Order, the Member shall only practice nursing where: (a) she has provided her employer s chief nursing officer, or equivalent, with a copy of the Agreed Statement of Facts and Joint Submission on Penalty or, if available, the Discipline Committee s Decision and Reasons. The Member will provide a letter from the employer to the Director within 14 days of the Member engaging in professional practice following the date that this Order becomes final, confirming: receipt of the Agreed Statement of Facts and Joint Submission on Penalty, or Decision and Reasons; an agreement to notify the Director immediately upon receipt of any reasonable information that the Member has failed to meet a standard of practice of the profession; and an agreement to provide the Director with performance appraisals regarding the Member s nursing practice completed by a member of the College as set out below in paragraph 3. iii.(b) after 3 months, 6 months, and 1 year of employment.

12 (b) The Member s employer provides to the Director performance appraisals completed by a member of the College after 3 months, 6 months, and 1 year of employment regarding the Member s nursing practice. iv) Upon obtaining employment in nursing and for a one year period of nursing practice, the Member must: (a) (b) (c) (d) develop a learning plan in consultation with a mentor approved of by the Director ( Mentor ). The Mentor must be provided with a copy of the panel s Decisions and Reasons in this matter. The Mentor must agree to provide to the Director a report every three months outlining that the Mentor has met with the Member as required and that the Member is implementing the learning plan and log as set out below; implement the learning plan and evaluate the results of the implementation with the Mentor every three months; maintain a log of any nursing errors or breaches of the standard of practice of the profession focussing on the reasons for the errors, the Member s approach to correcting the errors and how the Member will avoid making similar errors in the future, and review the contents of that log with the Mentor every three months; revise the learning plan if required to address any deficiencies in practice. Counsel for the College submitted that the focus of the penalty was on both specific and general deterrence. In regard to general deterrence the penalty sends a clear message to the membership about the need to follow the five rights of medication administration, the need for follow up if medication errors occur and the need to report errors and incidents. Nurses need to be able to self evaluate, to learn from their mistakes and improve their practice. The terms, limits and conditions included in the proposed penalty will act as specific deterrence and allow the Member to get advice and assistance from expert nurses, with a focus on remediation. The penalty was made for the Member and will serve to protect the public and support the Member. Counsel for the Member supported the Joint Submission on Penalty indicating that the penalty achieves many positive outcomes. The Member will have an opportunity for education, selfreflection and personal growth. Penalty Decision

13 The panel deliberated and accepts the Joint Submission as to Penalty and accordingly orders: 4. the Member to appear before the panel to be reprimanded; and 5. the Executive Director to suspend the Member s certificate of registration for 45 days; and 6. the Executive Director to impose the following terms, conditions, and limitations on the Member s certificate of registration: iv. That the Member provide evidence of successful completion of a course or courses in medication administration and documentation that has been approved of by the Director of Investigations and Hearings ( Director ), prior to returning to clinical practice and in any event within 12 months of the date of the panel s decision in this matter; v. That within 45 days of the date of the panel s decision in this matter, the Member meet with a College Practice Consultant. The Member will provide the Practice Consultant with the results of a Self-Reflective exercise that focuses on the issues of medication administration, documentation and professional responsibility and review with the Practice Consultant the results of the exercise and the College s Standards of Practice, and discuss the issues that arose in this case as they relate to the Member and her practice. The Member will complete a second Self- Reflective exercise regarding medication administration, documentation and professional responsibility and meet again with the Practice Consultant 10 months after the first meeting to review the results of the second exercise. vi. Until the Member has completed 12 months of practice following the date of this Order, the Member shall only practice nursing where: (a) she has provided her employer s chief nursing officer, or equivalent, with a copy of the Agreed Statement of Facts and Joint Submission on Penalty or, if available, the Discipline Committee s Decision and Reasons. The Member will provide a letter from the employer to the Director within 14 days of the Member engaging in professional practice following the date that this Order becomes final, confirming: receipt of the Agreed Statement of Facts and Joint Submission on Penalty, or Decision and Reasons;

14 an agreement to notify the Director immediately upon receipt of any reasonable information that the Member has failed to meet a standard of practice of the profession; and an agreement to provide the Director with performance appraisals regarding the Member s nursing practice completed by a member of the College as set out below in paragraph 3. iii.(b) after 3 months, 6 months, and 1 year of employment. (b) The Member s employer provides to the Director performance appraisals completed by a member of the College after 3 months, 6 months, and 1 year of employment regarding the Member s nursing practice. iv) Upon obtaining employment in nursing and for a one year period of nursing practice, the Member must: (a) (b) (c) (d) develop a learning plan in consultation with a mentor approved of by the Director ( Mentor ). The Mentor must be provided with a copy of the panel s Decisions and Reasons in this matter. The Mentor must agree to provide to the Director a report every three months outlining that the Mentor has met with the Member as required and that the Member is implementing the learning plan and log as set out below; implement the learning plan and evaluate the results of the implementation with the Mentor every three months; maintain a log of any nursing errors or breaches of the standard of practice of the profession focussing on the reasons for the errors, the Member s approach to correcting the errors and how the Member will avoid making similar errors in the future, and review the contents of that log with the Mentor every three months; revise the learning plan if required to address any deficiencies in practice. The panel concluded that the proposed penalty is reasonable and in the public interest. The panel found that the penalty addresses both general and specific deterrence. The panel felt that the Member needed the supports included in the penalty to ensure her safe practice. Nurses must refrain from practicing in circumstances which exceed their skills and abilities. Nurses must continually self reflect, identify their own learning needs, and ensure that they obtain the supports necessary for their professional growth and competency.

15 The panel felt that the penalty sends a strong message to the profession that members are accountable for their own practice. The public is protected when nurses adhere to the principles of quality assurance and continuous professional growth. I, Joanne Furletti RN, sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel as listed below: Joanne Furletti,Chairperson Date Panel Members: David Bishop, Public Member Dennis Curry, RN Denise Dietrich, RPN