Reflection on Medication Administration Incident

Reflection, Pages 5 (1167 words)

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“Reflection is not just a thoughtful practice, but a learning experience” (Jarvis 1992)

This comprehensive essay engages in a reflective analysis of an incident that occurred during a shift on the labour ward, employing Gibbs' model of reflection (1988) to guide the reflective process (Gibbs 1998) (Appendix I). Gibbs' six-stage model encompasses description, feelings, evaluation, analysis, conclusion, and an action plan, offering a structured approach to learning from experiences and improving future practice.

Description

The incident involved the inadvertent administration of a wrong opiate drug to a postnatal patient during the controlled drug check.

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The error was discovered by the coordinator and another midwife during the daily check, revealing a discrepancy in the number of Diamorphine 10mg and Morphine 10mg ampoules. Investigation indicated that myself, as the midwife checking the drug, and another midwife who administered the Diamorphine were the only individuals involved. Notably, the drugs were correct in the previous daily check.

Feelings

Upon learning of the error, initial feelings included disbelief and horror.

The realization that two midwives, including myself, failed to detect the mistake caused profound upset and embarrassment. As a qualified midwife, I had never encountered such an error before, intensifying my distress. Memories of being distracted during the drug administration process and engaging in unrelated conversations surfaced, leading to feelings of shame and anger at my own complacency. Concerns about potential harm to the patient and a sense of failure in upholding professional standards added to the emotional turmoil.

Evaluation

The paramount advantage in this incident is that the patient suffered no serious harm.

Personally, the experience served as a catalyst for learning and self-improvement. Reflecting on the incident, I acknowledged the need for increased vigilance and committed to avoiding complacency in drug administration. Adhering to the Standards for Medicine Management (NMC 2010), I implemented changes in my practice to prevent future drug errors, ensuring a higher standard of care.

Moreover, the incident has prompted a reassessment of the broader issues surrounding drug administration in nursing practice. Drug administration stands as one of the highest risk areas in nursing practice, demanding meticulous adherence to established procedures and standards (Gladstone 1995). Legal frameworks such as the Medicines Act (1968) and the NMC's Guidelines for the Administration of Medicines (2007) emphasize the importance of correct medication administration to ensure patient safety.

Analysis

Despite following local policies and procedures, the incident highlighted the unintentional administration of the wrong drug. The Consumer Protection Act 1987 and Medicines Act 1968 require that to administer medication, the practitioner has to ensure that the right medication is given, to the right patient, at the right time, in the right form of the drug, at the right dose and right route. Nursing & Midwifery Council’s Code of Professional Conduct (2004) emphasizes the administration of medication is an area of concern for public safety, and generally follows the principles laid down by law. The NMC also publishes the appropriate guidelines for nurses on the administration of medicines (NMC 2004).

The Standards for Medicine Management (NMC 2010) state 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 (NMC 2004), 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, and 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 confidence. The Guidelines for the Administration of Medicine by the Nursing and Midwifery Council advises that an open culture exists to encourage the immediate reporting of errors or incidents in the administration of medicines.

Furthermore, all errors and incidents have a thorough investigation at the local level, taking into account the full context of the circumstances, which requires sensitivity (NMC 2004). To learn from our mistakes, Williams (1996) believes we first need to acknowledge that we have made them. As mistakes in a professional capacity do happen, these mistakes need to be used as a learning experience to reflect upon and to therefore avoid them from happening again.

Conclusion

The administration of medicines is a critical aspect of a midwife's role, and errors can have significant consequences, including increased hospital stay, resource consumption, and potential harm to patients (Webster and Anderson 2002). Recognizing the gravity of drug errors, it becomes imperative for healthcare professionals to continually reflect on their practices, fostering a culture of accountability and improvement.

As healthcare providers, it is crucial to acknowledge the potential impact of drug errors on patient outcomes and the overall healthcare system. The incident discussed serves as a vivid reminder of the multifaceted nature of drug administration, requiring unwavering attention to detail and a commitment to ongoing education and self-improvement.

Action Plan

From my experiences with the incident, I have learned a valuable lesson that extends beyond individual improvement. I no longer allow myself to be distracted from other members of staff, patients, or relatives when I am in the process of administering medication. During this time, I only have discussions with the patient to whom I am giving the medication.

Moreover, I realize the seriousness of my error, and I have since read literature to educate myself further on the importance of not repeating the same mistake. My reflective practice has encompassed critical analysis of my self-awareness. Through this process, I have been able to learn from my mistake. The drug error incident has been a learning curve, and I now feel that I have improved my practice and become a better midwife, thus contributing to an overall enhancement of patient care.

Continued education and professional development will remain integral to my commitment to patient safety. I plan to engage in regular training sessions and stay updated on the latest developments in drug administration protocols. Collaborating with colleagues to share experiences and strategies for preventing similar incidents will also be a cornerstone of my ongoing commitment to continuous improvement.

In conclusion, the incident has catalyzed a multifaceted approach to self-improvement, encompassing not only individual practice but also a broader commitment to patient safety and the elevation of healthcare standards. As I continue to navigate my career as a midwife, I am dedicated to upholding the highest standards of care, learning from experiences, and actively contributing to a culture of continuous improvement within the healthcare profession.