Telephone Order, Controlled Drug and an Unlicensed Auxiliary on Night Duty
You are the only registered nurse on a 24-bed male medical ward during a 19:00–07:00 shift in a state hospital. Fourteen beds are occupied. Your colleague called in sick, so the ward is covered by you and one nursing auxiliary who has six months' experience and no practising licence. At 22:40, a postoperative patient with femoral traction reports 9/10 pain; the surgical registrar gives a telephone order for morphine 10 mg IV stat and says he will not attend the ward. At the same time, the auxiliary prepares to administer a prescribed dose of IV ceftriaxone to another patient because you are busy. The controlled-drug cupboard is in the treatment room, and the ward has a single-nurse signature policy when a second nurse is unavailable. You have 20 minutes before the next observation round is due.
1. Identify your immediate practice decisions about delegation and the IV antibiotic, and justify each decision with reference to nursing practice standards.
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The first decision is that the auxiliary must not administer IV ceftriaxone. IV medicine administration is a nursing act that requires a current licence and demonstrated competence; the auxiliary has neither. Delegation is not simply handing over a task because you are busy. It requires a licensed delegator, a competent delegate, a task within that person's scope, and adequate supervision. An IV antibiotic carries risks of anaphylaxis, extravasation, wrong-rate infusion and infection, none of which the auxiliary is prepared to manage. Tell her clearly to stop, take the prepared medicine from her, and check it yourself against the prescription and the patient's identity.
Second, re-order the work. Immediate priorities are the patient with 9/10 pain who may need assessment before analgesia, and the antibiotic whose scheduled time should be checked. If the antibiotic is not time-critical, a short documented delay while you assess the pain patient is safer than unsupervised administration. Ask the auxiliary to do only non-clinical supportive tasks she is trained for, such as fetching equipment, answering call bells and recording fluid balance under your supervision.
Third, escalate the staffing gap to the nurse in charge or duty manager and document the unsafe staffing level. The standard is not 'cover at all costs'; it is safe, accountable care within your scope, with unlicensed staff never used as substitutes for registered nurses.
2. Analyse how you should manage the telephone order for morphine, including assessment, witnessing, documentation and escalation if no second registered nurse can attend.
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A telephone order is acceptable only where hospital policy permits it and the prescriber is identifiable. Read the order back in full: patient name and ward, drug, dose, route, indication and prescriber's name and contact. Confirm the patient's allergies, current analgesia, respiratory rate, sedation score, blood pressure and pain score before giving an opioid. Morphine 10 mg IV is a significant dose; if the patient is opioid-naïve, respiratory rate is low, or there is head injury or hypotension, clarify the order with the registrar before administration.
Morphine is a controlled drug. Check the stock balance, enter the transaction in the controlled-drug register and obtain a witness. If no second registered nurse is on the ward, call the on-call nurse, house officer or anaesthetist to witness. Do not invent a witness, pre-sign the register, or ask the auxiliary to sign. If policy allows a single-nurse check in an emergency, follow it exactly and record why no second nurse was available. Administer, monitor respirations, sedation and pain, and document the order, read-back, assessment, administration and monitoring in the care record. Inform the registrar if the patient's condition changes or if the prescription needs review. Report the absence of a second checker and the doctor's refusal to attend through the incident-reporting system.
3. Outline the incident report and follow-up actions required after the shift.
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Complete an incident report describing facts, not opinions: staffing level, the auxiliary's attempt to give IV ceftriaxone, the telephone order, the absence of a second registered nurse for the controlled-drug check, and any delay in care. The incident report is for organisational learning and risk management; it does not replace the clinical record. Ensure the clinical notes contain the assessments, administration, monitoring and any variance.
Hand over the unresolved risks at shift handover: the unlicensed auxiliary, the single-nurse controlled-drug situation, and any outstanding medical review. Inform the nurse in charge and, if the risk remains, the duty manager in writing. Follow up with the ward manager about why an unlicensed auxiliary was rostered alone with a registered nurse and whether the hospital's delegation and controlled-drug policies match actual practice. Ask for a review of the single-nurse signature policy, staff training on delegation, and a controlled-drug audit. If the auxiliary had already administered the antibiotic, treat it as a medication incident, assess the patient, inform the prescriber, and apply duty of candour. Document the escalation and keep a copy of the incident report reference.