Reflection of Health Standards

This reflection discusses the importance of medication safety and effective communication in healthcare. It also highlights the consequences of medication errors and communication errors on patient health and healthcare professionals.

Running head: REFLECTION OF HEALTH STANDARDS
REFLECTION OF HEALTH STANDARDS
Name of the student:
Name of the university:
Author note:

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REFLECTION OF HEALTH STANDARDS
The first step of the reflective cycle is called the description change where the event
needs to be discussed in details. During the time of clinical placement, I had to work with
another colleague within a multidisciplinary team. A patient who had suffered a chronic heart
failure had been admitted to the rehabilitation ward for future treatment and recovery. I was to
work with association with that nurse in providing nursing care for the patient. However, while
providing care to the patient I noticed that the other nurse was not communicating with the
patient at all. Although, I was communicating well with the patient and listening to his concerns,
the other nurse was highly fidgety in actions and was an impatient listener. He interacted neither
with me nor with the patient. It was also seen that he was highly introvert and did not discuss
anything with me regarding the health of the patient. I asked the nurse to provide the food
instruction to the staff aid after discussing the type of diet the patient is comfortable. I saw the
nurse asking the patient the food he wants to have but did not listen to him completely. He cut
short the patient stating that he had understood. He told the staff nurse to bring vegetable salad
with cabbage, lettuce and other vegetables and asked him to bring a glass of milk. Later, the
preceptor was seen to get disappointed with the nurse as the patient had allergic infection due to
lettuce and cabbage and his taking of vegetables had interfered with the warfarin that was given
to him. He conducted medication error from drug-food interaction and breached effective
communication not listening to the patient’s allergic reactions with lettuce and cabbage and
cutting him shortly. He also did not communicate with team members and all these affected his
care. The patient had allergic reactions and the vitamin K in the salad components resulted in
antagonistic effects on the warfarin affecting health of the patient.
I felt quite upset seeing the suffering of the patient. I was also disappointed with myself
as I could not guide or help the nurse with my knowledge about the medication errors that took

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place. Moreover, I should have tried myself to communicate with the nurse although she was
introvert. I felt upset, as he had to suffer many consequences for providing unsafe interventions
for the patient. I also felt bad about the embarrassments he had to face when all the members of
the team were blaming of his ineffective communication skills and body language. I understood
that he need to develop his communication skills and drug-food interaction knowledge and
therefore proposed him to do so.
The third stage is the evaluation phase. In this incident, two health standards put forward
by the National Quality and Safety Health service standards. One of the most important
standards breached is the medication Safety standards. This standard mainly advises the nursing
professionals to follow systems as well as strategies that would help the professionals to properly
administer medications, prescribe them effectively and dispense them correctly (Lee et al.,
2018). They need to administer the medication to the patient effectively, monitor the use of the
medications and evaluate the effects of the medication. It was seen that the nurse in the incident
did not know that medication of warfarin and vitamin k of green leafy vegetables would interact
antagonistically and this might affect the health of the patient. Another standard that was also
breached is the standard 6 of the guideline standards that talks about the significance of
communicating for safety. This standard describes about the system and the strategies that are
important for continuing effective communication between patients, caregivers as well as
families, different multidisciplinary teams and clinicians and among the health service
organization (Goosen, 2015). The nurse communicated neither with the team members nor with
the patient that affected the health of the latter. Had he listened to the patient completely, he
would have knows that he is allergic to cabbage and lettuce and this could have avoided the
negative consciences of the patient.

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Medication error can have massive impacts. It results in increased suffering of the patient
as well as longer stays in the hospitals. Patients are often seen to be readmitted due to such errors
and it results in increased financial flow of the patients. It develops mental and emotional turmoil
among the patient and the family members making them depressed and anxious and these have
negative outcomes on the health of the patient. The healthcare professionals who get engaged in
such incidences also suffers from the feelings of guilt and loses their confidence and these affect
their practices (Vanderbeen & Butterfield , 2014). The healthcare organizations also suffer from
loss of resources that could have been kept for treatments that are more beneficial. The nurse did
not have the proper knowledge about the drug-food interaction (Sorensen et al., 2016). It is
extremely important for all professionals to follow medication protocols and develop skills and
knowledge by which medication safety can be ensured. Moreover, effective communication is
found to be extremely important for the healthcare professionals as it helps in the development of
therapeutic relationships with the patients (Wagner, 2018). It helps in maintaining their respect,
autonomy and dignity that empowers them and ensures patient satisfaction. Moreover, such
effective communication between the team members decreases the chances of errors and
promotes quality interventions (Belanger et al., 2017). The nurse did not listen to the patient fully
nor provided importance of what I was saying. Therefore, communication issues resulted in the
occurrences of such errors.
From the entire incidence, I learnt that medication error and communication error could
result in threatening situations of the health of the patient. If such a situation occurs again, I will
try to analyze the medication given to patient and then apply my knowledge and skills to decide
what food that needs to be given. Moreover, I will also communicate with my patient to develop

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therapeutic relationship with him and thereby document entire information of te patient and then
devise for the diet. Effective communication with team members would help in achieving team
goal as well.
Action plan:
I would develop my medication administrations knowledge by joining the training
sessions and going through different evidence based articles. I would also join workshops for
development of effective communication skills. Moreover, I will also consult with my mentors
and work accordingly to develop such skills.

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References:
Bélanger, L., Bourbonnais, A., Bernier, R., & Benoit, M. (2017). Communication between
nurses and family caregivers of hospitalised older persons: a literature review. Journal of
clinical nursing, 26(5-6), 609-619.
Goosen, S. (2015). Communication among nurses. Professional Nursing Today, 19(1), 18-20.
Lee, C. Y., Beanland, C., Goeman, D., Petrie, N., Petrie, B., Vise, F., ... & Elliott, R. A. (2018).
Improving medication safety for home nursing clients: A prospective observational study
of a novel clinical pharmacy service—The Visiting Pharmacist (ViP) study. Journal of
clinical pharmacy and therapeutics.
Sørensen, A. L., Nielsen, L. P., Poulsen, B. K., Lisby, M., & Mainz, J. (2016). Nurses
perceptions of the nurse-physician collaboration in relation to medication safety. In 4th
Nordic Conference on Research in Patient Safety and Quality in Healthcare. Publications
of the University of Eastern Finland.
Vanderveen, T. W., & Butterfield, R. D. (2014). U.S. Patent No. 8,672,875. Washington, DC:
U.S. Patent and Trademark Office.
Wagner, E. A. (2018). Improving Patient Care Outcomes Through Better Delegation-
Communication Between Nurses and Assistive Personnel. Journal of nursing care
quality, 33(2), 187-193.