Provision of medication following emergency request
Provision of medication following the request for emergency contraception
Deputy Health and Disability Commissioner Kevin Allan today released a report finding a registered nurse in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures relating to documentation and compliance with protocols for the emergency contraceptive pill (ECP).
A woman went to a medical centre for the ECP. The woman and the nurse have very different accounts of what occurred during the consultation, including what issues were raised and what medication was given. The notes that the nurse wrote up the next day indicate that the only medication given was an antibiotic used to treat sexually transmitted disease.
The nurse believes her notes do not reflect the treatment provided. She says she remembers discussing a number of issues, and giving the woman both the ECP and a different antibiotic (not documented), including further tablets to take at home.
The woman recalls being given two tablets to take at the medical centre but none to take home. She says she went to the medical centre solely to receive the ECP and did not raise other issues during the consultation. She subsequently discovered she was pregnant.
Mr Allan said the differing accounts were concerning and highlighted the importance of clear, accurate and, ideally, contemporaneous documentation.
"Due to the conflicting accounts from the woman and the nurse, and the incorrect and incomplete clinical notes, I am not able to determine exactly what occurred during the consultation. I note that the fact the woman became pregnant does not unequivocally prove that she was not given the emergency contraceptive pill. Regardless, there are many issues of concern with the nurse's clinical documentation," Mr Allan said.
Irrespective of whether or not the correct medication was supplied, the combination of documentation deficiencies described was unacceptable.
Mr Allan recommended that the nurse apologise to the woman, which she has done. He also recommended that the Nursing Council consider whether a review of the nurse’s competence is required.
The full report for case 17HDC01194 is available on the HDC website.