A nurse who gave chemotherapy to the wrong person because two patients had ‘similar sounding surnames’ has escaped punishment.
Lucy Joyce also made blunders in the administration of cancer medication for three other patients at the Leicester Royal Infirmary, the Nursing and Midwifery Council had heard.
But an NMC panel found Joyce’s personal health concerns at the time played a role in her clinical mistakes and she is now free to return to work at the University College Hospital of Coventry and Warwickshire without restriction.
Bryony Dongray, for the NMC had told the hearing: ‘This case involves four separate incidents that happened between May 1 2013 and May 18 2015.
‘The incidents in question are similar in terms of that they all involve errors in the administration of chemotherapy medication.
‘On May 1 2013 Joyce was supervising a newly qualified nurse who brought Patient A into the treatment room at around 10 o’clock.
‘She should have brought in another patient, Patient B.
‘The patients had the same first name and similar sounding surnames and Patient B was brought in error.
‘Identification checks were not made properly by the registrant, this was an other error.
‘Chemotherapy treatment meant for Patient B was given to Patient A, another nurse realised what was happening and stopped it.
‘Luckily no harm came to either patient.’
Joyce did not witness the treatment and then wrote in her notes that she had, the hearing was told.
For two other patients pre-hydration medication was not given alongside the chemotherapy drugs, said Ms Dongray.
‘They should have been given concurrently,’ she said.
‘This increased the risk of toxicity of the chemotherapy medication.’
On another occasion Joyce allowed irimotecan, a drug used to treat colon and rectal cancer, to be administered to a patient within one hour of the drug cetuximab.
The drugs should never be administered within one hour of each other as it is against treatment guidelines and put the patient at risk.
Joyce admitted that she did not ensure identification checks were carried out for Patient A, did not witness the chemotherapy and then recorded that she had.
She also admitted to not administering pre-hydration medication for two patients and administering irimotecan within one hour of the administration of cetuximab.
Joyce denied her fitness to practice is currently impaired and the NMC panel agreed.
NMC panel chair Ilana Tessler said: ‘The panel noted that the mistakes you made between May 2013 and May 2015 were of a clinical nature and could therefore be addressed by training and further clinical experience.
‘In addition, the panel recognised that you were experiencing adverse health consequences at the time you made the mistakes.
‘With regard to your insight, the panel noted that despite not being required to administer chemotherapy drugs in your new role at the Coventry Trust, you voluntarily completed a chemotherapy competency assessment.
‘The panel considered this to show that you know exactly where your deficiencies lie and have chosen to address them.’
‘In addition, the panel considered your insight to have improved over time.
‘You explained with hindsight, how you should have acted at the time of the first mistake and how in the aftermath you should have recognised the adverse effect it was having on your health, noting that you should have withdrawn yourself from a clinical setting.
‘In light of these factors the panel concluded that you currently have a high level of insight into both the mistakes you made previously and your health condition.’
‘The panel had regard to the very positive references from the two consultants who work alongside you every day and the fact you have worked successfully without incident as a Band 7 nurse since November 2015.
‘Taking all of these factors into account the panel concluded that you have fully remediated your failings and were highly unlikely in the future to: put patients at unwarranted risk of harm; bring the profession into disrepute; or breach a fundamental tenet of the profession.’
‘The panel has determined that your fitness to practise is not currently impaired.’