Model of Reflection of Nursing Student

Running head: REFLECTION
REFLECTION
Name of the Student
Name of the University
Author Note

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Diary entry
I have used Driscoll’s model of reflection for reflecting on my nursing experience.
This reflection about a 65 old man who was suffering from pulmonary fibrosis. He had been
admitted with an acute exacerbation of respiratory disease. He was reviewed by a respiratory
specialist and a nursing trainee. I was also appointed to take care of the patient. However, the
patient improved after the administration of an antibiotic and the steroid dose of the patient
was increased. The discharge was planned. The patient was prescribed with 100 mg
allopurinol with an increase of 100 mg every two weeks. Some of the other medicines that
were prescribed are Nifedipine, urosemide, and azathioprine. These medicines were
mentioned in a separate form and the pharmacy failed to notice that this was the second
prescription. The nurse trainee in charge also failed to notice this. This incident occurred
when, my shift was over. Next day, however, prior to the discharge, while I was going
through the discharge summary, I noticed the combination of the two medicines.
Allopurinol and azathioprine should not be prescribed together, as allopurinol
interferes with the metabolism of azathioprine, which increases the plasma levels of 6-
mercaptopurine that can cause fatal dyscrasias (Chai & Coleman, 2015). However, the matter
was informed to the doctor. The prescription was cancelled. The doctor and higher authorities
were informed about the matter. The incident was flagged as a “near miss” in the incident
reports of the hospitals. Both the pharmacist and the enrolled nurse was show caused.
Level 1
What?
The issue was about the prescription of the wrong dosage of medicines. The involvement was
about the prescription of wrong dosage of medicines by the pharmacist. Although, I was
allotted to care for the patient. The incident occurred after the shift timing is over. The

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incident came to my notice as I was going through the discharge summary, the next day.
However, I prompt to bring this matter to the notice of the doctor for checking the
prescription. I reported about the incident and fully cooperated with administrators while the
investigation was being carried out. I was not entitled to the question the pharmacist for the
mistake, but I enquired about the matter from the nurse trainee about his irresponsible
behaviour. I initially believed that it was all the fault of the nurse, trainee, but later on
realized that there was something bigger and grave. I was aware of the fact, that there were
shortage of the nursing staffs in our department and the nurses often have to work overtime in
order to compete the work. The nurse admitted that she had been less mindful these days due
to excessive workload on his shoulder.
The medical error was recorded as a “near miss” which could have had some serious
consequences if not detected earlier.
The good point for the experience, that I had done my duty appropriately and have
taken proactive steps to inform to the higher authorities and make sure that the novice nurses
do not repeat the same mistake. While I was on my shift, I made sure that I use both the
verbal and the non-verbal communication techniques. I have worked as per the ethical codes
of nurses and have thought, that if these incidents were not marked in the incident report and
is not informed to the higher authority, these mistakes might repeat itself. While enquiring the
novice nurse, I was perturbed by the thought as what would the trainee nurse think, if he was
being called for a one –on –one session.
The bad thing about this experience is how anxious I was, as I also had an onus, since,
I was caring for the patient too. I realised that the patient could have been harmed. I was
concerned by the fact that our renowned health care system have gaps in them, to allow the
potential errors to slip through the holes. I was well aware of the fact that, the matter could

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have gone unnoticed and the patient could have been discharged. However, I could not
imagine, what would have happened, if the patient was discharge without revising the drug
dosages .Another good thing about the incident is that a comprehensive training has been
taken place after this incident, where the other nurses were present. In this training session,
enrolled nurses and the nurse trainee could have some peer interaction with the seniors and
have received some valuable feedbacks, which can be really helpful to the novice nurses.
Level 3
So what?
This incident have illustrated the potential for a medical errors and it could be found
that these mistakes are usually due to the combination of certain systemic as well as
individual factors. This incident has been upsetting and useful at the same time, but it have
the potential to change my attitude and make me more mindful and resilient while dealing
with medical errors. While, I was feeling disappointed due to the mistake committed by my
peers, but at the same time I feel more educated and prepared. Analysing the severity of the
mistake, it can be said that this incident could have some very serious consequences. One is
the potential of these medicines to generate an adverse drug reaction. Azathioprine is an
immunosuppressive agent. It is first metabolised to 6-mercaptopurine, which is actually
converted to inactive products by the use of Xanthine oxidase. Allopurinol inhibits the second
step of the metabolism and higher 6-mercaptopurine plasma level results that is associated
with the toxic effects on the bone marrow and other tissues. A health care professional, or any
other providers of healthcare should ensure that the patient is not allergic to any of the
prescribed drug or no medication is prescribed, if there is a chance of contraindication
(Shahrokhi, Ebrahimpour & Ghodousi, 2013). It has been identified in literatures, that there
are three most common dispensing errors,that are generally committed by pharmacists. These
are dispensing of an incorrect medication, the strength of the dosage, miscalculation of the

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dosage and failing to under the drug contraindications. However, it cannot be said the
pharmacist was not well aware of the contraindications, but there had been some errors in the
documentation process and the prescribing process. Prescribing errors, accounts up to almost
11 % of the prescriptions, with a cost of around £350 million per year. About 16 % of
prescription errors have been found to harm the patients and it can be found that most of the
errors had been preventable. There are several reasons for taking an accurate medical history,
before the prescription of any medicines. A knowledge of the medications the patient has
been taking or have taken in the past generally helps in planning a future treatment
(Abbasinazari, Talasaz, Eshraghi & Sahraei, 2013). Drug effects has to be on the list of
differential diagnosis, as drugs can cause illness, either directly or due to interaction with the
drugs. It should be noted that drugs can mask clinical manifestations and it an also alter the
results of the investigation. Apart, from this, a patient should always be discussed about the
mode of action of the medicines in a simpler way, such that they can understand as of exactly
what they are consuming. A drug which has been prescribed in error will not be checked
unless a pharmacist checks the prescription of the patient. Hence, it is the duty of the
pharmacist to check carefully, if the patient have multiple prescriptions (Odukoya, Stone &
Chui, 2014). As stated earlier, I have already stated that , I have had a conversation with the
nurse trainee, although not with the pharmacist, I have come to know that the number of
nurses in the ward are too low and it becomes very difficult for a nurse to manage everything
single handed.
Errors in the medication history can be classified in to omission errors, dose errors
and frequency errors and the dose errors. About 65% of the patients at least had one
medication errors on admission to the general medicine wards of the hospital (Vazin, Zamani
& Hatam, 2014). It can be said that, a medication history should not only be a list of the drugs
and the dosages of the patient. Some of the other information like adherence to the therapy or

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any previous cases of hypersensitivity reaction, should also be reported and should be
compared with the general practitioner of the patient. While taking the history from the
patient, it is necessary to elicit the information like the current prescribed drugs, formulations,
routes of drug administration, duration of the treatment and the frequencies, or previous
hypersensitivity reactions, time course and their nature (Mirsadeghi, Iraqi & Mollahadi,
2019). Safe assessment and administration of the medication is one of the important standards
of NMBA (NMBA, 2016). According to the NMBA standard, a nurse should be able to use
appropriate processes for identifying and report potential and the actual risk related system
issues and where the care standard is less than the expected standards (NMBA, 2016).
Furthermore, it has also been mentioned by the novice nurse, that shortage of nursing
staffs had been one of the reasons for their lack of mindfulness and concentration.
Mohammad Nejad et al., (2013) have considered the shortage of the nurses to be one of the
most important reason for medication errors. Some of the most important reasons for the
mediation errors are fatigue due to excessive work, shortage of the nurses, long working
hours and high workloads in the unit. Absenteeism and high turnover rates has been
associated to inadequate staffing levels, which can place the patient at risk. Hence, the fact of
nursing staff shortage can be considered. However, patient’s interest should always be at the
first place and a health care professionally is ethically and legally obligated to do no harm to
the patient.
As mentioned in the description, the event was described as a near miss, and
previously it was not recorded officially, unless I intervened and emphasized this entire
incident to record in written form. Collection of the near miss assists to create a culture that
identifies and control hazards that will reduce the risks and the potential for controlling harm
and hazards which will reduce the risk and the potential for any harm.

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Now what?
This incident has been an eye opener for me and I have understood how small
mistakes can lead to big medication errors, which is also detrimental for the life of the people.
I intend to go through a number of the articles about the prescribing errors and the probable
ways to prevent such mistakes. I personally will ensure greater responsibility while
administering medications and would cross check the prescriptions before setting a patient
from discharge. It is better to follow the 5 rights of medication administration to prevent the
medication errors such as the right patient, right drug, the right, the right route and the right
time.
I ensure, that I will never fill the testing and treatment history form (TTH) form
without the being clear about all the medications of the patient. Furthermore, I intend to be
more proactive in reporting such near misses. Voluntary reporting entirely depends upon the
awareness of the health care providers depends upon the awareness and hence many of the
reports remain unreported. The percentage of the reporting of adverse events is estimated to
be within the range from 50-60 %. Despite this record, the medication errors reporting in the
medical care practice is normally done in an informal manner. In some cases the errors are
discussed in an informal manner (Elden & Ismail, 2016). The reports should always be in
written reports. The improvement for the patient safety opportunities will be limited. It can be
recommended that that there should be a non-punitive environment for the error reporting. A
punitive culture actually prevents the hospitals from getting the actual error rates. It is
necessary to remove the culture of individual blame. The near miss incident needs to be
investigated for identifying the root cause and the weakness in the system which resulted in
the situation of the near miss. This culture would make the hospital staffs more vigilant and
observant that they look for the potential system flaws (Aboshaiqah, 2013). It is necessary to
encourage the staffs to look for the potential errors and risks and point them out for

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improving the patient safety. If an employee has repeated records of mistakes, then he/she
should be given a warning. The investigation report needs to be used for improving the safety
systems, risk reduction and the lessons learned. A policy and procedure needs to be
communicated to all the employees. Again, it is necessary to communicate on the importance
of the reporting of the near misses (Cornes et al., 2017).
There should be provisions for the stress management and the resilience training
programs for the reduction of the stress and improve the resiliency of the staffs. Such
programs can be developed in the organisation (Chesak et al., 2017). Resiliency training has
been found to be important to relieve stress. Furthermore, it is necessary to reflect on the
nursing activities (Hamaideh, Al-Omari & Al-Modallal, 2017). Reflective activities in
nursing assists the nurses to examine the actions and the experiences with the outcome of
developing their practice and enhancing the clinical knowledge. Reflective practices assists
nurses to identify individual strengths and weaknesses (Howatson-Jones, 2016). Feedback
can be taken from the seniors for understanding the flaws in their care.
In conclusion, it can be stated, that medication error is an important reason for the
mortality caused due adverse drug reactions in a hospital setting. Annual deaths from
medication errors account for about 7000 out of the total number of deaths. The medication
error in this case has been committed by the pharmacist and the novice nurse who had failed t
recheck the prescription and thus an increased dosage of medicine. This mistake could have
caused serious implication in the patient, which could have led to legal lawsuits. It could also
deteriorate the position of a care setting causing patients to drop out from the treatment
regimen. I have learnt that careful assessment and cross checking of the prescriptions needs
to be made before a patient have been discharged. Furthermore, I have also learnt that
mandatory reporting is necessary for preventing similar mistakes in future. Furthermore, I
also intend to continue life learning to improve my knowledge about medical errors.

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References
Abbasinazari, M., Talasaz, A. H., Eshraghi, A., & Sahraei, Z. (2013). Detection and
management of medication errors in internal wards of a teaching hospital by clinical
pharmacists. Acta Medica Iranica, 482-486. Retrieved from
http://acta.tums.ac.ir/index.php/acta/article/view/4407
Aboshaiqah, A. E. (2013). Barriers in reporting medication administration errors as perceived
by nurses in Saudi Arabia. Middle-East Journal of Scientific Research, 17(2), 130-
136. DOI: 10.5829/idosi.mejsr.2013.17.02.76110
Chai, M. O., & Coleman, A. (2015). Using allopurinol to prevent and manage hyperuricaemia
in a patient with chronic kidney disease. journal of renal nursing, 7(2), 78-82.
Chesak, S. S., Bhagra, A., Schroeder, D. R., Foy, D. A., Cutshall, S. M., & Sood, A. (2015).
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Howatson-Jones, L. (2016). Reflective practice in nursing. Learning Matters.
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