A Reflection on a Clinical Experience: Medication Errors

This article discusses a nurse's experience with medication errors and the importance of proper education and coordination in nursing care. The nurse witnessed a colleague administering a wrong dose to an elderly patient and failing to consult with other healthcare team members. Insufficient knowledge of medication and skills is identified as a major problem in nursing practice. The article suggests ways to reduce the risk of medication errors, such as double-checking medications with other nurses and consulting senior nurses for advice.

Running Head: MEDICATION ERRORS 1
A Reflection on a Clinical Experience: Medication Errors
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Medication is an important nursing responsibility and skill even though it takes
nurses a long time to master the skill (Jarvill et al., 2018). Errors during the administration
of medicines to patients have escalated with time and can put the safety of patients at risk
(Ofusu & Jarret, 2015). The principles of beneficence and non-maleficence require nurses to
maximize good while administering care to patients and not cause harm. This issue of error
in medication does not only involve wrong calculations of doses but also the number of
doses administered to patients in a day. I preferred this aspect of care (medication) because I
happen to have witnessed a nurse administering a wrong dose to one of her elderly patients.
The nurse did not look at the patient's medical chart before administering the medicine to
the patient. Later on, it occurred to her that the dose had already been administered to the
patient. She therefore firmly stated that the patient should stay in bed for six hours.
Nurses are expected to be very careful when administering care to patients
especially when dealing with vulnerable groups of people. The nurse should have checked
the patient’s medical chart before administering the dose. Consistent cross-checking of a
patient’s medical chart and records should be at the fingertips of every nurse. The nurse
failed in her professional obligation to patients. Moreover, the nurse did not consult her
colleagues on how to go about the issue. She instead firmly requested the patient to stay in
bed for six hours. The National law of Australia and the Nurses and Midwifery Board of
Australia requires nurses to mandatorily report any information that may affect a patient’s
health especially if the patient is very vulnerable (Nursing and Midwifery Board of
Australia, 2014). In this case study, the patient was aged but the nurse did not report the
issue of wrong administration of a dose.
The major reason why nurses could be making errors in medication is that of
insufficient knowledge of medication; mainly in drug management (Simonsen et al., 2014).
The constant increase in the number of errors in the administration of medicines means that
there is a gap in the nursing education system in Australia. The nursing education needs to
be planned and implemented well in order to improve the quality of patients’ care. If the
nurse had enough knowledge, she might not have administered a wrong dose to the patient.
Therefore, it is necessary that the skills of nurses in drug management constantly sharpened
in order to avoid the compromise of a patient’s safety.
I think the nurse neglected her duty of care owed to patients so I was actually
infuriated. What if it would have been her victim? Nurses have a duty to care for patients
and administer quality care especially to the vulnerable groups of people. The patient
probably felt short-changed by the nurse. The patient expected the nurse to take care of her

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but instead, the nurse compromised her safety by administering a wrong dose to her. The
nurse's colleagues felt betrayed by their co-worker. Nurses are expected to coordinate and
consult with their colleagues when they are faced with a medical challenge. Even after
administering a wrong dose to the patient, the nurse chose to withhold the information from
her co-workers.
The reason why I was angry is that I was once a victim of wrong administration of a
dose. I had been admitted to a hospital due to constant stomach pains. The nurse who was in
charge of examined my situation before referring me to the doctor. The doctor then
instructed me to inject me with a dose of quinine. However, the nurse injected a wrong part
on my upper left arm thereby causing a swelling on my upper left arm. This justifies my
infuriation. I felt like I was the one going through the same wrong process again. My
personal values have also influenced this aspect of care. I always think that the vulnerable
deserve a quality nursing care. Therefore, seeing an aged person receiving a wrong dose of
medicine makes me feel like advocating for a change in the drug management education.
The theory of deontology requires nurses to execute their duties and ethical
obligations responsibly without causing harm to patients (Acosta, 2017). Nurses are also
bound by certain codes of conduct and ethics that require them to act ethically, legally and
professionally when dealing with patients. However, patients' safety has been jeopardized
by the inaccuracy in the administration of medicines. Medical errors have escalated to
become a source of mortality for patients (Zaree et al., 2017). This is the major reason why
the education of nurses needs to be improved. The development of nursing knowledge and
skills reduces the risk of medication errors thereby improving the health care of the society
(Jalil Eslamian, 2015).
In order to reduce the possibility of medication errors I will; coordinate with the
other healthcare team members, clarify and outline interdisciplinary orders, always ask for
and offer assistance to my colleagues, make good use of evidence-informed guidelines,
communicate information to patients and the hospital health workers and ensure that the
hospital is adequately staffed with nurses to allow safe provision of care (Delamont, 2013).
Double checking medications with other nurses and consulting senior nurse for advice
greatly reduces the risk of medication errors. Based on my experience, I would regularly
check the patient’s medical chart and records before administering a dose. In case I make an
error, I will report the issue to the hospital’s senior health workers in order to get assistance
and advice. That would definitely help me improve my skills as well as ensure the safety of
patients.

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In conclusion, the prime problem in the nursing practice is insufficient knowledge of
medicine and skills. If the education process of nurses can be structured to cover all
possibilities and impossibilities then the challenge of medication errors will be solved. This
experience will make me a better nurse because I know the guidelines to follow when
handling patients. My sense of morality will also enable me to take care of patients
diligently.

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