The nurses within the Colorado Board of Nursing should be – and most likely are – ashamed of their misguided actions. This story of a suffering child made to bear more pain in their first and last hours on Earth is nothing short of horrifying (Calfee & Plum, 1997). Had the nurses taken an introspective look at what exactly they were doing, they would have been able to identify the flaws in judgement they were making, which are in direct violation of the State Nurse Practice Act. Being nurses in Colorado, they would have had a Board of Nursing which discusses the correct instances and applications of advanced drug therapy (Board of Nursing Rules, 2017). This instance was definitely not in the stipulated procedure, and a mis dosage of ten times greater than what was needed does not fall within an acceptable margin of error. According to section 2.2 of the nursing regulations, licensed practical nurses are allowed to administer intravenous treatment but most keep their patients’ comfort and care above all else (Board of Nursing Rules, 2017). In addition, dosages are crucial in drug therapy, they must be specified in the health records and must be checked multiple times to ensure they are right. All RXNs involved then must sign that they understand the gravity of their decision and know that they are going to be held responsible (Watson, 2014). No matter the intention of these three nurses, their professional instincts are what spurred their mistake, and that above all is what should be being analyzed.
If every case were judged only on the intention behind it, there would be no concrete rules of ethics or practice within nursing. Only a true sociopath would intentionally hurt an infant to this point; the thought behind the action does not matter as much as the decision (Watson, 2014). Occupations of this scale, which deal with life and death issues, require more training and protections than other less vital positions. Thus, nursing and doctoral malpractice of this scale require a more severe punishment than those others. The knowledge that they are being held to their actions should not deter any nurses’ view of their job or role – this is something they should have been aware of from the beginning of their training. Nurses who go against their formal training are knowingly breaking their code of ethics to provide the safest and most effective treatment to patients as possible, and should be treated as so.

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  • Board of Nursing Rules.pdf. (2017). Colorado State Board of Nursing. Retrieved 14 August 2017, from
  • Calfee, B. E, & Plum, S. D. (1997). Nurses indicted: Three Denver nurses face prison
    in a case that bodes ill for the profession. Retrieved from http://business.
  • Johns, C., & Freshwater, D. (Eds.). (2009). Transforming nursing through reflective practice. John Wiley & Sons.
  • Watson, E. (2014). Nursing malpractice: costs, trends, and issues. J Leg Nurse Consult, 25(1), 26e31.