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Patient Safety Essay On Suspension Of A Registered Nurse


Task: Identify a case from the NSW Nurses and Midwives’ Board or HCCC, Caselaw or AHPRA website which involved a registered nurse(s) who had their registration cancelled or suspended for greater than 6 months due to their involvement in an adverse event for a patient in their care.

Access the following websites and choose a case that fits the description above (see highlighted terms) and that interests you.

NB: You need to provide the reference number and link to the case (the full case not a summary) – your assessment cannot be marked without it

NB: If your case involves more than 1 RN you can discuss them all in your essay


Background of the scenario of patient safety essay:
According to the article selected to prepare this patient safety essay, Mr. Kevin Picones was 27 years registered nurse at the period of the hearing. He registered himself as nurse on February, 2014. In NSW regional city, March, 2015 he began service as a registered nurse at a child and adolescent mental health unit. This mental unit delivers care to the young individuals and children. A complaint was received against Mr. Picones, before the Tribunal (NSW Civil and Administrative Tribunal) that alleged that he failed to provide proper nursing care and haven’t maintained proper professional limits regarding his nursing care to three timid patients in the CAMHS department on 2015 at Orange Hospital. (Health Care Complaints Commission, 2018) Patient X was only 15 years old at the time of the incident and was admitted to the child and adolescent mental health unit involuntarily for about five months because of self-harming tendency, emotional dysregulation and extreme suicidal thought. Patient Y was admitted to the CAMHS unit at the age of 14 for four and half months and was diagnosed with anorexia, also in the pediatric department with extremely low weight along with her menstrual cycle. Patient Z, a 16 years old adolescent was admitted to the hospital with an addiction of benzodiazepine. He spent almost six weeks in the unit before he was discharge to a rehabilitation center.

Patient Z reported to a staff member on 2nd September, 2015 that he was given Phenergan on multiple occasions by Mr. Picones, even when it was neither charted nor prescribed to him. Also, he helped some patients to smoke and gave his cell phone to a patient. On 22nd September, 2015 patient Y also reported the incident of the drug administration to her under similar circumstances to another staff member. (Health Care Complaints Commission, 2014) Patient X also joined in on this conversation and put a similar allegation on Mr, Picones, along with the names of few other patients who had been given the same drug.

As per the readings utilized in the patient safety essay it can be stated that in an internal investigation which was conducted in October, 2015, there were further allegations on Mr. Picones which surfaced including making cigarettes accessible to the patients, disclosure of other staff member’s personal information, non-intervention in case of self-harm by a patient in his presence, and passing sexual comments.

In April, 2016, it is clear on this patient safety essay that Mr, Picones took employment in Nepean hospital in some other district, in their older person unit, leaving his old job in March, 2016. Nepean was not informed by him about his ongoing investigation and the workplace restrictions imposed on him.

According to the local district health June 2016 report considered in the scenario of patient safety essay, the district suggested a warning that if the name of Mr.Picones is on the service registered list and continues to work as an employ of the district, he will be placed on corrective improvement plan based particularly on his performance. The LHD report also mentioned that in future all employee/staff those are working with CAMHS need to have minimum experience of 3 years of post-graduation and training relevant to the post-graduation area as well. A report copy was also given to the Nepean hospital and by receiving the report copy, the hospital suspended registered nurse Mr. for 4 months from the clinical practice. Eventually after conducting its specific risk assessment Nepean hospital allowed Mr.Picones to rejoin his duties but with certain restrictions like only day shift, supervision and obligatory online education.

Actions on the part of the Registered Nurse that contributed to the adverse outcome for the patient:
Several reasons where there that contributed to the adverse event Mr. Picones was not able to provide proper care to the patients because of which they were put at risk.

The major issue outlined in the context of patient safety essay that put him into trouble was the supply of Phenergan tablet to patient X, Y and Z. In the statement that was given by Mr.Picones he stated that he used to spent a lot of time every day on the unit with a group of 4 patients those were his friend including patients X,Y,Z and Patient Four. As they were his friends and Phenergan is an antihistamine that helps in sleeping they asked Mr.Picones to give them the tablet and eventually he provided them with the 2X tablet of it on 16th of Sep,2015. (Taylor, Aug 2018)

Although, it is also discussed in the patient safety essay that he was aware of the Nsw medication handling policy that all medicines including Panadol at the time of administrating patients under the age of 16 should be charted and need to be administered in the company of two nurse. Despite the fact he provided the patients the tablet without consulting with any other nurses. Remarkably, he characterized the tablet as something to help with mild insomnia. So, on the basis of his statement he should have provided the Phenergan late at night to the patients when they were facing difficulty in sleeping. (Taylor, Aug 2018)

The instances mentioned above within this patient safety essay are the evidence of Mr. Picones altering his statements repeatedly and hedging himself from his responsibilities. His statement that the patients were ‘begging’ and ‘pleading’ for the medications and other favors from him, is another incidence of him trying to evade from his responsibility. Also, in his oral statements, he stated that he was ‘giving in’ and ‘pressured’, even though use of Phenergan was suggested by him.

On 16th September afternoon during his shift Mr. Picones also escorted Patient Z out for a walk and allowed him to smoke a cigarette for about 5 minutes as he was getting discharge and it was the patient’s last day in the unit. (NSW Caselaw, 2018) He also had a conversation with the patient while walking, about the personal matters of the other staff members.

Mr.Picones also gave Patient Z hisown mobile phone in order to login Facebook account. He also tried to stalk other staff members through his own Facebook account.

Besides the fact noted herein patient safety essay that each and every medicine given to the patients should be registered in the chart along with a signature of two registered nurses, Mr. Picones did not maintained a proper documentation. Perhaps he was accused of providing Valium, Temazepam and Tramadol medicines to the Patient Z whenever he asked for it.

Omissions on the part of the Registered Nurse that contributed to the adverse outcome for the patient:
There were several lapses in duty by Mr. Picones as illustrated in the segments of patient safety essay. Mental health patients in their adolescence, are more vulnerable to exploitation because of their psychological and emotional immaturity, which made the irresponsible behavior of Picones a bigger issue. One of the major omissions that he did was not to chart the medications he was giving to the patients, as it is mandatory for a nurse to write down the medications given to a patient. On several occasions he was found to have given various medications to patients without writing them down. Another lapse in the service occurred when the nurse did not stop ore report the patients when they were asking for favors such as cigarettes or cell phone from him. Instead, he ended up providing these prohibited items to them on more than one occasions. In another allegation, he was accused of being negligent to a patient who was displaying self-harm behavior. As a registered nurse in a mental health ward, it becomes absolutely necessary for the nurse to intervene when there is a probability of patient to self-harm. (NSW Caselaw, 2018) He had also failed to intervene in any form when he had found two patients in sexual situation, wherein as a nurse it was his duty to put restrictions on the patients. On top of that, Mr. Picones even passed sexual remarks to patient X.

If Picones was finding it difficult to manage the patients, he could have asked for help from other nursing staff instead of going against the code of conduct for the registered nurses. He even failed to inform the Nepean hospital about his ongoing investigation while switching jobs, which is a breach of trust of the employer.

What are the other factors that may have contributed to the adverse outcome for the patient examined in the patient safety essay?
It was not the mistake of the Mr. Picones only; there were few issues that can be identified from the hospital administration side as well. The appointment of a relatively inexperienced nurse in a mental health ward with vulnerable patients is highly questionable. The appointments should be done based on the experience and past track record, and for the relatively new nurses, it is safer for them to be put in the care of adults and elderly where there is a lesser chance of being harassed or exploitation. Also, there were lapses on the part of the Nepean hospital, when they hired a new nurse without proper background checks. (Health Care Complaints Commission, 2018) Had they been thorough in the checks, Picones would not have the chance to get employment in any other place. The hospital premises can also be installed with cameras for surveillance, so that if there are allegations by any patient about any form of misconduct by a nurse, there will be ready proofs available to prove or disprove them.

Actions that should have been undertaken by the Registered Nurse to prevent the adverse outcome for the patient:
It can be stated herein patient safety essay that as a responsible care taker Mr. Picones should not have administered un-prescribed medications to the patients on the first hand. Even if he deemed these medications necessary in any situation, he should have either informed a doctor and should have charted the same in the patient’s records. If he was being pressured by the patients to provide them the medicines or any other kind of favors, he should have reported them to the authorities instead of giving in on their demands. (Ahpra & National Boards, 2012) There was no need for him to provide access to his cell phone to the patients. Also, if he had encountered any patient in objectionable conditions, he should have intervened and reported the same. He should also have restrained himself from commenting on other staff member’s personal life. In case of patient safety essay, he was not able to handle the patients on his own, he should have asked for additional staff from the hospital. Also, he should have admitted any mistakes that he may have committed, as being proven guilty at a later point of time during investigations would make the matter worse for him.

Ahpra & National Boards, 2012. Court and Tribunal Decisions. [Online]
Available at:
[Accessed 20 4 2020].

Health Care Complaints Commission, 2014. Case studies. [Online]
Available at:
[Accessed 20 4 2020].

Health Care Complaints Commission, 2018. RN Kevin Picones – Registration cancelled for professional misconduct. Patient safety essay [Online]
Available at:
[Accessed 19 4 2020].

NSW Caselaw, 2018. Health Care Complaints Commission v Picones [2018] NSWCATOD 56. [Online]
Available at:
[Accessed 17 April 2020].

Taylor, D., Aug 2018. Evidence in practice: Sedating Antihistamines - do they still have a role?. Australian Pharmacist, , Vol. 37( No. 7), pp. 50-59.


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