Series of errors lead to dismissal
A nurse at Chinook Regional Hospital in Lethbridge, Alta., continued to make egregious errors, leading to her eventually being dismissed.
Marilyn Brown worked as a registered nurse at Alberta Health Services (AHS) since 1979, and worked at the Chinook location since 1997.
Brown was terminated on July 21, 2015, after an incorrect administration of magnesium sulphate, which was a culminating incident, according to AHS.
On Sept. 17, 2013, Brown was given a one-day suspension for “committing false witness to narcotic wastages” and failure to properly document medications. As well, she was cited for sharing her computer’s user ID and password.
The suspension was initiated by Joyce Nay, unit manager, who discovered that a patient was given an incorrect dosage of Tylenol 3 pills. A co-worker of Brown’s told Nay that when the elderly patient was provided with two pills, as per the proper prescription, the patient refused and said the previous time Brown only gave out one pill.
In double-checking the chart, the co-worker found that Brown wrote down she had given the patient two pills.
Nay began to investigate Brown’s previous charting and found several other errors. Another nurse told Nay that she felt pressured by Brown to sign that she had witnessed narcotic waste, when she hadn’t.
Another disciplinary matter came to light on Aug. 19 after Brown told Nay that she had shared her computer password with her husband so he could check on her paycheck.
Nay told Brown to immediately change her password, but during a Sept. 10 investigation meeting, Brown said she hadn’t yet changed it.
She was suspended and off work as of Sept. 19.
Brown and the union, United Nurses of Alberta (UNA), grieved the suspension but arbitrator Lyle Kanee (with Marty Sholtz and George Courts making up the arbitration board) upheld it.
“AHS proved (Brown) made a number of charting errors, signed as witness when a co-worker charted that she drew the medications on two different occasions when both doses were drawn at the same time, and failed to change her password after being asked by her supervisor three times to do so. These incidents gave AHS just cause for discipline.”
On Feb. 13, 2014, Brown was suspended five days for violating the catheter management protocol on more than one occasion.
On June 17, Brown was given another five-day suspension for incorrect documentation of a narcotic count tab and improper procedures during a blood transfusion. As well, Brown was cited for medication dispensing errors and “improper disposal of morphine down the sink.”
During a meeting on June 15, Brown could not recall some of the incidents and she didn’t have any proper explanations, testified Kevin Elder, unit manager.
Brown remembered the narcotics disposal incident, but she said she became confused after hearing another patient make a noise from another room.
Again, Brown grieved the suspension, but “AHS proved, on a balance of probabilities, that (Brown) asked a co-worker to witness wastage after the medication had been wasted and she wasted the medication in the sink instead of the sharp container. (Brown) admitted these events in the investigation meeting,” said Kanee.
Finally, on July 21, Brown was fired for not following the “magnesium sulphate policy when providing care for a patient.”
The dismissal was also grieved, but “AHS established that (Brown) programmed the pump to administer magnesium sulphate at rates that were unsafe and contrary to the applicable policy,” said Kanee.
The arbitrator found that the culminating series of incidents leading to the termination was justified, and he dismissed the final grievance.
“In the investigation meetings, (Brown) rarely accepted responsibility for her misconduct and offered no explanations that would mitigate the misconduct. In the investigation into the magnesium sulphate pump issue, (Brown) claimed she relied upon a different policy yet no other policy was produced in evidence. When provided with a pump and asked to program it, she was unable to do so,” said Kanee.
“Regrettably, as (Brown) did not testify, any reasons for her rapid deterioration after decades of solid performance remain a mystery to this panel.”
Reference: Alberta Health Services and United Nurses of Alberta. Lyle Kanee — arbitrator. Erin Ludwig, Stephanie Arsenault for the employer. Marilyn Vavasour for the employee. March 12, 2018. 2018 CarswellAlta 530
