“Reflection is not just a thoughtful practice, but a learning experience”. (Jarvis 1992) This is a reflection on an incident that occurred during a shift on the labour ward. I have chosen Gibbs model of reflection (1988) to guide my reflective process. (Gibbs 1998) (Appendix I). Gibbs model (1998) goes through six important points to aid the reflective process, including description of incident, feelings, evaluation, analysis, conclusion and finally action plan. The advantage of Gibbs’s six-stage model is that it allows you to learn from experiences and make changes for your future practice. Description The incident involves the administration of a wrong opiate drug to a postnatal patient. The incident occurred whilst checking and …show more content…
The NMC also publish the appropriate guidelines for nurses on the administration of medicines (NMC 2004). The Standards for Medicine Management (NMC 2010) states that I am “accountable for your actions and omissions”. This incident has highlighted the need for vigilance at all times. Rule 7 of the Midwives Rules and Standards (NMC2004), states that “A practising midwife shall only supply and administer those medicines, including analgesics, in respect of which she has received appropriate training as to us, dosage and method of administration”. Although the local policy and procedures were followed, it seems that unintentionally the incorrect drug was administered. As a registered midwife I am up to date with all training, I have never before in my practice made a drug error. Research studies demonstrate that many drug errors within clinical practice occur as a result of distractions on the ward, illegible writing or because nurses failed to check the patient 's name-band (Gladstone 1996). The incident discussed demonstrates how easily practitioners can become distracted when checking and administrating drugs. With regard to reporting drug errors, (Webster and Anderson 2002) found that several areas of concern emerged, including nurses ' confusion regarding the definition of drug errors and the appropriate actions to take when they occurred. Nurses also reported their fear of disciplinary action and the loss of their clinical
Medication errors in the hospital setting have significant potential to result in serious injury and even death, thus effecting patients, families, health care professionals, and hospitals. Approximately 400,000 adverse drug effects (ADE) occur each year (Institute of Medicine, 2006). Considering that not all medication errors are discovered and reported, this number is likely to be underestimated. These errors not only contribute to patient morbidity and mortality, but also cause increased length of stay and hospital expenses. It is estimated by the Institute of Medicine (IOM) that $3.5 billion is spent annually as a result of ADEs (IOM, 2006).
Medication errors are preventable and cause great harm to the patients and their families. Every year in Australian hospitals, medication errors occur as nurses do not follow the 9 rights of medication administration. The 9 rights are right patient, drug, route, time, documentation, response, action and form (Fossum et al., 2016). Medication errors can be caused by
While this is a serious error by institutional standards, it fails to meet the tort definition of negligence. There was a duty of care to this patient who was admitted to the hospital. A breach of that duty occurred when the patient was given the incorrect medication. The requirement of injury necessary to meet the definition of negligence was not me. There was no reported adverse outcome reported from the single dose of the incorrect medication. Due to lack of injury, there appears to be no risk to the institution from negligence surrounding the medication
This article will look at two articles and focus on aspects of safety medication administration in nursing practice by the staff nurses. This is interesting area because the previous report on the medication administration error in the UK shows that approximately 5.6% of doses administered to adult hospital patients and it has been estimated that 0.6-1.2% of medication administration errors may lead to severe harm even death (Mcleod et al, 2013). Leape et al (1995) indicated that nurses were responsible for 86% of all medication error interception, regardless of the original errors. The nurses play the important role in identifying the causes of medication errors and preventing medication administration errors in nursing practice in order to provide safe care toward the service users (Henneman et al, 2010). The Medicines and Healthcare Products Regulatory Agency (MHRA 2004) documented that the health professionals need to effectively and safely use medicines to ensure patients get the maximum benefit from the medicine; meanwhile minimizing the potential harm. This article will be critiqued on the different types of evidence which explored safety medication administration in the nursing practice toward service user. Using evidence is important in nursing practice because it can help nurses in addressing questions related to best possible care and improve patients’ outcome. It is embedded within the code the nurses are expected to use best possible evidence in the nursing
The National Patient Safety Agency (NPSA 2010), defines a drug error as ‘any preventable event that may cause or lead to inappropriate use of patient harm. Although not all drug errors have lead to patient harm it is important to recognise that if a mistakes has been
In this case study I will use Gibbs (1988) model of reflection to write a personal account of an abdominal examination carried out in general practice under the supervision of my mentor, utilising the skills taught during the module thus far.
Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.
The administration of medication can be associated with a significant risk with it is recognized as a central feature of the nursing role. It should continue in order to avoid a possible medical malpractice continuous care. Nursing staff have a unique role usually given to patients to manage their medication and responsibilities, then they can report these identified medication errors. Some of the most distinguishable events can be related to errors in professional practice, prescribing, dispensing, distribution, and education or monitoring. Since medication errors can arise at any state of the administration process, it is essential for nursing staff to be attentive of the most commonly encountered errors. For the most part, the common of the perceptible aspects related with medication errors are due to minimal awareness about hospital policies, inappropriate implementation or latent conditions (Farinde, n.d).
Nurses are responsible for multiple patients on any given day making medication errors a potential problem in the nursing field. Medication administration not only encompasses passing medication to the patients yet begins with the physician prescribing the medication, pharmacy filling the correct prescription and ending with the nurse administering and monitoring the patient for any adverse effect from the medication. According to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), ‘A medication error refers to any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional,
There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.
As clinical site co-ordinator with many years of clinical experience I feel competent in the drug administration via a variety of routes. Generally the patients I attend have become acutely unwell with most prescriptions not having the third eye of a pharmacist and most drugs being delivered intravenously. It is imperative therefore that the prescription and drugs always be thoroughly checked which relies on good communication throughout. Furthermore, most emergency drugs have a protocol for administration developed by the hospital. However within this situation the nurse is generally the last defence before any medication error actually occurs, therefore it is the nurses responsibility to ensure the prescription is correct and to challenge prescription written
Medication errors are focused on: terms and definitions; incidence of and harm; risk factors; avoidance; disclosure, legalities & consequences (Wittich, Burkle & Lanier, 2014). Medication errors categories have been developed by the American Society of Health-System Pharmacists (ASHP). Examples of these categories are based on prescribing, omitting drugs not administered, timing, unauthorized drug, wrong dosage, wrong preparation, expired drug, not using laboratory data to monitor toxicity (Wittich, Burkle & Lanier, 2014). Additionally, this article examines in depth common causes leading to medication errors, drug nomenclature, similar sounding drugs, unapproved abbreviations and handwriting, medical staff shortages and manufacturer medication shortages. Even though this article provides an informative overview for physicians, other allied health personnel may benefit too. This is valuable knowledge for the health care professional not just physicians in order to provide safe care for their
Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error
An error is one of the vital parts of human life. Hospitals are areas with very chaotic systems and as health care is growing more steadily, it is becoming complex in nature and more sophisticated technologically. Therefore, medical errors are bound to happen. Administrators, physicians, and nurses, are advocates of patient safety and safety is one of the highest priorities during the provision of care. A report from Institute of Medicine (IOM) claims that between 44,000 and 98,000 die annually due to medical errors (Alexander, Cheryl Ann 2014). Medication errors can lead to adverse outcomes such as increased mortality, extended period of hospitalization, and amplified medical expenses. Although the health care team can cause medication errors, nursing medication errors are the most common. Moreover the workload of the nurses combined with more prescription
Safe medication practices are key to every nurse since it results to safe medication administration. When medication is not administered correctly it results to adverse drug event which refers to harm to the patient that includes mental harm, physical harm, or loss of function which is as a result of a medication error (practices, 2017). Medication errors occur when a mistake is committed by a person administering medication and in order to avoid these errors safe medication practices need to be adhered to. Some of these