Nurse who gave wrong dosage to baby found guilty of misconduct

A nurse who gave the wrong dose of drugs to a baby in intensive care and deliberately hid her error, has been found guilty of professional misconduct.

Nurse Donna Chavez who worked in Our Lady’s Hospital, Crumlin, administered the incorrect dose of adrenalin and noradrenalin to a child who was in a critical condition in intensive care over a period of six hours in September 2012.

Ms Chavez admitted altering the medical notes to hide her mistake and not informing other members of staff about what she had done.

The committee will send its report and recommendations to the board which will determine what sanctions, if any, to impose on Ms Chavez.

The baby was in the paediatric intensive care unit following an operation to put a band on his pulmonary artery.

The inquiry heard Ms Chavez put a decimal point in the wrong place when she administered the infusion of drugs which meant that 10 times the recommended amount was given to the child over the six hour period.

She later realised her mistake but did not inform any other staff member and altered the record of administering the drugs on the recording system.

The following day, nurse Deirdre O’Connor noticed the wrong amount of drugs had been administered and Ms Chavez admitted her mistake at a disciplinary meeting.

Barrister for Ms Chavez, Rosemary Mallon, said her client admitted at the opening of the inquiry her actions amount to professional misconduct.

The inquiry heard Ms Chavez had been a nurse for over 20 years and had worked in the Philippines andSaudi Arabia.

She had worked in Crumlin hospital since 2007 and no previous issues or concerns had been raised about her before the incident.

Following the incident, Ms Chavez took part in a number of training and educational courses including safe practice and medication management course.

Witness Dr Robert Greally who was working in the paediatric intensive care unit at the time told the inquiry he could not be certain if the medication error affected the child’s condition or what impact, if any, it had on the child.

Nurse Tracey Wall said Ms Chavez was suspended and a full investigation into the incident was set up which she fully complied with.

Ms Wall said structures were put in place to support Ms Chavez as she was anxious and upset about what had happened.

Ms Chavez was transferred to the “less acute” outpatient department of the hospital to work under supervision, Ms Wall said.

As part of the developmental plan Ms Chavez attended an Irish Nurses and Midwives Organisation safety workshop, an in-house IV study day, a course of clinical record keeping and a medication e-learning programme.

Ms Chavez said during the disciplinary meeting, she offered to resign twice because she was “so ashamed” of what she had done.

She said she was “regretful and extremely remorseful” for what she did and was sorry to the patient and their family.

Ms Mallon asked the committee to look at the case in a lenient way and said she was confident Ms Chavez would not repeat this mistake again.

When asked why she left Crumlin Hospital in 2013 despite being offered guidance and to keep her job she said it was "self punishment."

Ms Chavez broke down several times giving evidence and said she was scared she would lose her job because she is the breadwinner of her family because her four sons and husband live in the Philippines.

The inquiry heard Ms Chavez resigned from her position at Crumlin Hospital in December 2012 and now works as a senior nurse in an adult hospital.