Medication error, honesty and the duty of candour
You are a newly registered nurse on a care of the elderly ward. During a busy drug round you administer 10 mg of oxycodone to Mr Patel instead of the prescribed 5 mg because you misread the chart. Two hours later he is drowsy, with a respiratory rate of 9 and SpO2 92% on air. He is usually alert and mobilising. You realise the error when checking the chart for the next patient. The ward manager is off duty; the nurse in charge is a band 5 colleague who says 'just monitor him, don't make a fuss, it'll blow over'.
1. What are your immediate clinical and professional actions?
Read the worked answer
Patient safety first, then honesty, then reporting.
Clinical:
- Assess the patient now - ABCDE, respiratory rate, SpO2, sedation score, blood pressure, pain, responsiveness.
- Escalate to the on-call doctor/outreach immediately; opioid toxicity with RR 9 is a medical emergency. Be ready for naloxone per prescription/protocol.
- Stop further doses, keep the chart with you, and monitor continuously until stable.
- Position to maintain airway, give oxygen if prescribed, and document observations.
Professional: 5. Tell the truth to the patient (and family if appropriate) - duty of candour: a notifiable safety incident requires an open, honest explanation and apology. An apology is not an admission of liability. 6. Report the incident on the incident reporting system (e.g. Datix) as soon as the patient is safe - this is not optional and is not about blame; it is for learning and safety. 7. Inform the nurse in charge and the ward manager, and complete an incident form. The colleague's advice not to report is not acceptable; you remain accountable for your own practice. 8. Document contemporaneously and factually: what was prescribed, what was given, when, the observations, who was informed, and the actions taken.
Standards: NMC Code - be open and honest, act immediately to put matters right, report errors, and prioritise people. The duty of candour is a legal and professional obligation.
2. The colleague tells you not to report it. How do you handle this, and what would you do if the ward manager also discouraged reporting?
Read the worked answer
You are accountable for your own practice; no colleague can override that.
- Acknowledge the colleague's concern (fear of blame, workload) but be clear: 'I understand, but this is a reportable incident and the patient needs to be safe. I'm going to report it and escalate.'
- Report anyway. Incident reporting is a professional duty and supports organisational learning. Failure to report can itself be a fitness-to-practise matter.
- Escalate up the chain if discouraged: nurse in charge → ward manager → matron → divisional lead → freedom to speak up guardian. Keep a factual record of who said what and when.
- Use the Freedom to Speak Up process if you are being pressured not to report; this is protected.
- Reflect and learn - what contributed (interruptions, similar-looking charts, fatigue)? Suggest a change (e.g. separate storage of different strengths, double-check for opioids).
If the ward manager discourages reporting: this is a serious concern. Follow the local raising-concerns policy, contact the freedom to speak up guardian, and if necessary the NMC/CQC routes. Do not collude in concealment.
Standards: NMC Code - 'be open and honest... act without delay... report any errors'. Accountability is personal and cannot be delegated.