A paediatric nurse intern facing disciplinary action for allegedly giving strong sedatives to children is denying she did so without a prescription or supervision.
The nurse, who has interim name suppression, appeared before the Health Practitioners Disciplinary Tribunal in Auckland today on day two of the hearing.
She is accused of medical misconduct for treatment provided to two patients in March and June 2017.
The charges against her allege that while working as a registered nurse and clinical nurse specialist intern at an Auckland hospital's emergency department she gave the drugs Propofol, Fentanyl and Ketamine to two patients without a prescription and supervision.
She is also accused of not providing full and accurate clinical notes.
In a statement of evidence given at the hearing, the nurse denied all charges of administering the drugs without a prescription or supervision.
"While I agree to some and/or part of the charges laid in relation to my documentation, I deny the charges laid that I did not have supervision or I did not obtain a verbal order from a senior medical officer, and was therefore practising outside my scope," she said.
The nurse said a very large part of her role was to undertake procedural sedations, including administering Propofol and Fentanyl, and in terms of her patients she would discuss them all with a supervising doctor.
"They would then decide whether they would see the child themselves or if they were happy with my assessment and plan, they would provide me with verbal orders and then allow me to continue with the discussed plan," she said.
"While this supervision was indirect rather than direct, I considered that such supervision was appropriate."
The nurse also said she thought she was qualified to administer the drugs due to a course she had attended.
"At this workshop the use of Propofol combined with Ketamine was discussed as being a potential option for some paediatric patients in certain circumstances," she said.
"While I did initially think (mistakenly) that by attending these courses, I was credentialed to use Propofol and Fentanyl - that does not change the fact that I always had direct or indirect supervision from a senior medical officer in relation to all my procedural sedations."
A witness statement provided yesterday gave detail of how the sedative Propofol shouldn't be given to a patient without a senior registrar or consultant being present.
Due to side affects of the drug, it is always administered in the resuscitation room in case the patient requires resuscitation and airway management.
In terms of Ketamine, nurses need to be credentialed before they could administer it.
Tribunal notes state the nurse in question had this credential, which meant she "was able to administer, if necessary, the prescribed dose of Ketamine with a medical practitioner in the room".
Fentanyl must be prescribed and is not able to be given under a standing order.
In March 2017, the nurse allegedly treated a 15-year-old boy with a fractured ankle.
The patient was required to be "quite heavily sedated" in order to plaster the wound, Tribunal notes said.
Records show the nurse administered Ketamine, Propofol and Fentanyl. However, it is alleged none of these drugs were prescribed or documented on the patient's medical chart.
The nurse said she gained a verbal order to administer the sedatives, but she couldn't recall who gave the order.
However, she said this order was witnessed by at least two other nursing staff, including a registered nurse and a doctor, and she received consent from the parents.
"While it is not up to [the doctor] or any orthopaedic registrar on what sedation is used, I would expect that if he had concerns he would voice them, as would the other doctor and nurse in the room at the time. However, no concerns were raised," she said.
The nurse explained that for this patient, the procedure was time-sensitive and pressured and using Ketamine alone was not sufficient as it doesn't last for long.
She explained that the patient was also tall, fit and weighed 90kg.
She said Fentanyl and Propofol were used due to the time the procedure took, and the pain the patient was suffering from.
"I completed the sedation knowing that if the situation became complex, I could call for help from my supervising senior medical officer if required who would have been close by."
Later in June 2017, the nurse treated an 11-year-old girl who had fallen at home and suffered a broken leg.
This girl also suffered from ADHD, obesity, autism and sleep apnoea.
Records show the nurse administered Ketamine and Propofol, and again these medications allegedly weren't prescribed or documented.
A witness statement given yesterday described how a patient with these conditions shouldn't be given such sedatives unless it was "absolutely necessary".
The nurse in question explained that she initially wasn't told about the patient's conditions, and that the patient was again large, heavy and tall for her age.
"As patient B's weight was well above average for a child of this age, giving Ketamine alone is not a viable option for procedural sedation, especially when performing a more challenging and lengthy procedure such as this one," she said.
"As I would have discussed with my supervising senior medical officer, children/adults with autism or ADHD require a lot more sedation medications because they have a higher threshold for these medications."
When questioned by the prosecution, QC Matthew McClelland, the nurse admitted there were no records of any discussions with consultants for these two patients, and she should have followed the correct procedure and got someone to sign off her notes.
However, she said any mistakes came down to a lack of understanding of the verbal order requirements, and a lack of mentoring support in her role.
In witness statements yesterday, it was ascertained nursing interns should be provided with a mentor, however, the nurse in question explained how she only met formally with her mentors four times during the span of a year.
"I think if I had been better supported, had a regular mentor, and been better informed - I wouldn't have made these errors," she said.
The Tribunal will decide whether the nurse's actions in administering the drugs allegedly without a prescription or supervision, and not documenting them correctly, compromised the safety of the patients and amounted to professional misconduct.
A decision is expected later this week.