Decision of the Disciplinary Panel
IN THE MATTER OF THE COLLEGE OF REGISTERED NURSES OF BRITISH COLUMBIA (the "CRNBC") and IN THE MATTER OF A HEARING PURSUANT TO SECTION 38 OF THE HEALTH PROFESSIONS ACT INTO THE CONDUCT OF JULIET WALSH, R.N. REGISTRATION NO. 745491 (the “Registrant”)
From February 1, 2010 to February 10, 2010, in Terrace British Columbia, a Disciplinary Hearing was held under section 38 of the Health Professions Act into the conduct and competence of Ms. Juliet K. Walsh, Registered Nurse, Registration No. 745491, while employed as a registered nurse at Mills Memorial Hospital in Terrace, British Columbia from August, 2000 to April 22, 2009. Prior to its decision the Panel reviewed the written transcripts, exhibits and evidence presented at the hearing by both the College of Registered Nurses of B.C. (hereinafter referred to as the “College”) and Ms. Juliet Walsh (hereinafter referred to as “Ms. Walsh”). As discussed with the parties at the commencement of the hearing, this decision is concerned solely with the question of whether any elements of the Citation have been proven. There will be further proceedings to consider what remedies, if any, are appropriate under Section 39(2) of the Health Professions Act (the “Act”).
The amended citation alleged that Ms. Walsh:
a) Failed to comply with the College's standards for the practice of nursing by registrants and standards of professional ethics for registrants, including
(i) Standards 1, 2, 3, 4 and 5 of the College's Professional Standards for Registered Nurses and Nurse Practitioners; (ii) Part l.A of the Canadian Nurses Association Code of Ethics for Registered Nurses; and/or (iii) The College's Practice Standards on Medications and on Documentation;
(i) Standards 1, 2, 3, 4 and 5 of the College's Professional Standards for Registered Nurses and Nurse Practitioners;
(ii) Part l.A of the Canadian Nurses Association Code of Ethics for Registered Nurses; and/or
(iii) The College's Practice Standards on Medications and on Documentation;
b) Committed professional misconduct or unprofessional conduct; and/orc) Incompetently practiced nursing.
After considering the particulars of the allegations presented in the Further Amended Citation and the evidence and arguments presented during the hearing of this matter, the Panel makes the following findings of fact:
1(a) On or about January 10 or 24, 2007, Ms. Walsh failed to properly execute protocol UGIAJFFOX with respect to a patient. Specifically, a 100 ml bag of D5W was used for the IV rather than a 250 ml bag, resulting in the patient receiving an incorrect concentration of Calcium Gluconate and Magnesium Sulfate.
1(b) On or about January 24, 2007, Ms. Walsh incorrectly administered the drug Trastuzumab to a patient by running the intravenous pump at 800 cc/hour, rather than 600 cc/hour.
1(c) On or about March 7, 2007, Ms. Walsh failed to properly execute protocol UGIAJFFOX with respect to a patient by neglecting to release a clamp on the administrative set resulting in the patient not receiving chemotherapy as per the physician's orders.
1(h) On at least one occasion while working in the Oncology unit between November of 2006 and January of 2007, Ms. Walsh exhibited a lack of familiarity with the expected procedure for blood transfusions, hanging Lasix in a minibag and then putting the major flush bag on a secondary line, causing excess air to go into the saline line because there was little to no saline on the main port.
1(i) On at least one occasion while working in Oncology, Ms. Walsh set out two 100 ml bags of saline along with two amps of Benadryl for a colleague to later administer to a patient. This was inconsistent with the protocol which called for two 50 ml bags of saline and one amp of Benadryl and one amp of Hydrocortisone as pre-medications.
1(j) On one occasion while working in Oncology, Ms. Walsh changed the weight on a patient’s chemotherapy physician's instructions sheet and failed to recalculate the patient’s BSA.
1(k) On or about March 30, 2009 Ms. Walsh reported to a colleague she had started a minibag of IV Gravol on a post operative patient (Laparoscopic Cholecystectomy) who was nauseated. When the colleague checked the patient, she found the Gravol diluted in 100 cc normal saline and running at a very slow rate (approximately 25 cc/hour) which meant the Gravol would take four hours to infuse, rather than the 15-30 minute time frame stated in the Parenteral Drug Administration Manual for Infusion and Dilution Rate. When this was brought to Ms. Walsh’s attention by her colleague, Laurie Dahms, Ms. Walsh appeared confused about the infusion rate. In her direct evidence, Ms Walsh remarked that she thought the IV was positional, however other evidence presented by Laurie Dahms disputed this. Ms. Walsh in her direct testimony was unable to calculate the correct infusion rate using a 100ml of saline rather than 50 ml of saline. Furthermore, Ms. Walsh was unable to substantiate her claim that the IV in question was positional. The Panel finds that Ms. Dahms’ evidence is the more reliable and so prefers her evidence on these points.
1(l) On or about April 15, 2009 Ms. Walsh demonstrated a lack of critical thinking and professional decision making when a patient was discharged without notifying the doctor that the patient had a heart rate of 30 beats per minute and no measurable blood pressure.
2(a) On more than one occasion Ms. Walsh reacted defensively and/or made excuses when errors or omissions were brought to her attention by supervisors and/or colleagues as outlined in Ms. Walsh’s letter to Shari Yeast dated Dec 6, 2001 and Peer Appraisal dated March 7, 2007;
2(b) Ms. Walsh failed to improve nursing practice even though errors and omissions had been brought to her attention on several occasions. These errors and omissions were outlined in her performance appraisal dated Dec 4, 2001, the peer appraisal dated Mar 7, 2007, Barbara Caldwell’s memorandum dated March 8, 2007 and Dr. Fourie’s letter dated March 16, 2007.
3(d) On or about January 10 or 24, 2007, with respect to the incident of an incorrect concentration of Calcium Gluconate and Magnesium Sulfate, when this matter was brought to Ms. Walsh’s attention by a colleague and evidence of this error was presented to her, Ms. Walsh argued with her colleague and did not follow her suggestions for correcting the situation.
3(e), 4(a) On more than one occasion, by failing to access available sources for information and support Ms. Walsh placed unnecessary burdens on colleagues by taking much longer than normal to carry out her expected duties and by asking questions of colleagues which Ms. Walsh could have resolved herself by accessing available resources. On or about January 10 or January 24, 2007 Ms. Walsh did not review or understand Protocol UGIAJFFOX as she administered calcium gluconate and magnesium sulfate using a 100 ml bag of D5W instead of a 250 ml bag. On or about Jan 24, 2007 Ms. Walsh did not review or understand Protocol BRRAACDT and the appropriate rate of infusion for the drug trastuzumab and set the IV pump at a faster rate than stipulated in the Protocol.
3(g) Errors and omissions by Ms. Walsh resulted in an increased workload for colleagues as they were required to intervene in order to correct the situation where possible and/or to reassure patients. In addition to the facts set out in the preceding paragraph, on or about March 30, 2009 Ms. Walsh miscalculated the dilution and/or the rate of infusion of gravol in a post-operative patient.
5(d) Ms. Walsh in direct evidence and cross examination gave information regarding an allegation that in December, 2002 she sent an emergency room patient with chest pains to the lab for an ECG. Ms. Walsh did not acknowledge her error in judgment with respect to this incident and rationalized her decision which is contrary to practice standards and hospital procedure.
5(f) On or about March 7, 2007, supervisors met with Ms. Walsh to outline concerns about nursing practice and expectations for improvement.
5(g) In July 2007, a supervisor spoke to Ms. Walsh regarding an inability to prepare patients on time for surgery.
5(h) On Dec 4, 2001, February, 2002, Jan 10 or Jan 24, 2007, March 7, 2007 and March 30, 2009 colleagues brought to Ms. Walsh’s attention errors or omissions regarding nursing practice. Despite this Ms. Walsh failed to correct the behaviours associated with the identified practice concerns.
Based on these findings of fact, the panel finds that Ms. Walsh has failed to meet the following Standards:
Responsibility and Accountability - Maintains standards of nursing practice and professional conduct determined by CRNBC and the practice setting.
Specialized body of Knowledge - Bases practice on the best evidence from nursing science and other sciences and humanities.
Competent Application of Knowledge - Makes decisions about actual or potential problems and strengths, plans and performs interventions, and evaluates outcomes.
Code of Ethics - Adheres to the ethical standards of the nursing profession.
Provision of service in the public interest - Provides nursing services and collaborates with other members of the health care team in providing health care services.
The panel finds that Ms. Walsh has also failed to meet Part 1.A of the Canadian Nurses Association Code of Ethics for Registered Nurses. Providing Safe, Compassionate, Competent and ethical care as well as the CRNBC Practice Standard for Medications in regards to “seven rights” of medication administration and principals that support safe medication administration.(right medication, right client, right dose, right time, right route, right reason, right documentation).The Panel further finds that in not meeting the above noted standards, Ms. Walsh has incompetently practiced nursing and presents a significant risk to the public. A pattern of serious medication errors and lack of critical thinking and professional decision making was established from 2007 to 2009. The specific errors were well documented and substantiated with reliable evidence. Many of the errors were acknowledged by Ms. Walsh in her evidence and cross examination.
Specifically, the Panel finds that as per the Amended Citation;
It is also the decision of the Panel that Ms. Walsh has shown unprofessional conduct in regards to what witnesses observed were defensive and angry reactions to their feedback, criticism and direction. In spite of numerous concerns expressed to her, Ms. Walsh did not improve her practice.
Ms. Walsh stated in her testimony that she has a growing awareness of a tendency to go into shock and shut down when faced with criticism. She notes that she becomes extremely anxious and her focus and perceptions become narrowed and that the resulting mental stress causes her to be unable to comprehend criticism. Indeed, she stated that she would have difficulty with her hearing and vision. Ms. Walsh acknowledged that this is not an effective coping mechanism. She suggested that others may have misinterpreted this response as angry and defensive. The Panel accepted as reliable, testimony from several of Ms. Walsh’s co-workers and managers (Margaret McDaniels, Marnie Matthews and Laurie Dahms) and their observations that Ms. Walsh appeared angry or vague, or had no response to serious incidents. Notwithstanding Ms. Walsh’s intentions it was apparent to the Panel that she was unable or unwilling to make the changes necessary to improve her practice and to ensure safe care of patients.
Ms. Walsh acknowledged and showed remorse for a number of the errors in regards to critical thinking, judgment and medication management. However, it was clear to the Panel, from the evidence, that Ms. Walsh was often not prepared to accept criticism directed towards her. Her lack of judgment and critical thinking abilities was most evident following her discharge of a patient with a pulse rate of 30. When this was brought to her attention, her response was to write a Professional Responsibility Form about faulty blood pressure equipment. In another situation, it was Ms. Walsh’s testimony that perhaps safeguards be put into place for a double check of clamps (related to the incident where a patient was sent home without the clamp being released on an administrative set). This causes the Panel to conclude that Ms. Walsh is minimizing her own responsibility as this suggestion would not be a reasonable expectation of nursing practice.
The Panel recognizes that the College, in its closing submission, made the statement that it was not necessary to find that all of Ms. Walsh’s nursing care at Mills Memorial Hospital was incompetent, and the Panel does not. Several witnesses acknowledged that Ms. Walsh is a caring and compassionate nurse.
The Panel also acknowledges the College’s stated position that “a finding of incompetence is not necessarily a professional death sentence with no chance for remediation.”
In reference to (a) (iii) of the Further Amended Citation, the College has not submitted evidence to specifically support its allegation of a failure by Ms. Walsh to meet the practice standard in regards to Documentation. Accordingly, the Panel makes no findings in this regard.
Allegations regarding the specific event of running the drug Lasix through a mini bag when it should have been given by IV push were not substantiated. The excerpt from the Parenteral Drug Administration Manual provided to the Panel indicates that hospital protocol permitted Gravol to be given by IV infusion.
The allegation that Ms. Walsh refused to give medications through IV push were general, non-specific and denied by Ms. Walsh. Accordingly, the Panel makes no findings in this regard.
The allegation that while working in day care Ms. Walsh interrupted colleagues while they were interviewing patients who were being admitted, and that these interruptions led to colleagues being behind schedule, was not substantiated with sufficient evidence and accordingly the Panel makes no findings in this regard.
The evidence relating to Ms. Walsh arriving late for her shift was general and was not documented with specific incidents and circumstances. It also appeared to the Panel to be more of a Human Resources concern. As a result, the Panel makes no findings in this regard.
The Panel has not made any findings with respect to allegations 1(f), 1(g), 3(a), 5(a), 5(b), 5(c) and 5(e). This is due to the lack of specific evidence in respect of these events, lack of firsthand accounts, poor recollections, lack of substantiating evidence and the fact that a significant amount of time has passed from these incidents.
The Panel, after consideration of the evidence and arguments presented before it, finds that Ms. Walsh has committed unprofessional conduct pursuant to Section 39 (1)(c) and has incompetently practiced as a Registered Nurse pursuant to Section 39 (1) (d).
The Panel orders pursuant to Section 39.3 (1) (d) of the Act that the Registrar of the College notify the public of this Order.
Having made the findings in this decision, the Panel will contact the parties to seek submissions with respect to the appropriate remedy under Section 39(2) of the Act.
Pursuant to Section 39 (3) (d) of the Health Professions Act, the Panel notes that Ms. Walsh may appeal this decision to the Supreme Court of British Columbia, pursuant to section 40 of the Act.