NRSG367 Assessment - Critical Reflection on Past Clinical Practice Experience

Running head: NRSG367 ASSESSMENT 2 REFLECTION
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Title page
Student Name:
Semester 1, 2020
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NRSG367 ASSESSMENT 2 REFLECTION 2
Introduction:
The paper will give a critical reflection on a past clinical practice experience and
relate those experience to one or two of the NSQHS (National Safety and Quality
Health Service Standard) standards. This form of reflective exercise will help to
determine how the clinical experience helped in developing knowledge related to patient
safety and enhancing the quality of care.
Standard
1. Description The standard chosen is medication safety standard which
lays down the procedure needed to reduce adverse medication events
and improve safety and quality of medication use. Clinical governance,
correct documentation, continuity of medication management and
adherence to best practice related to administration of medication are
some of the elements of this standard (Australian Commission on Safety
and Quality in Health Care (ACSQHC), 2017). During my clinical
experience, I was involved in providing care to a 67 year patient who
came to the ward after a knee surgery. As per the handover instruction, I
was supposed to administer an analgesic to patient. However, after I
prepared the medication, I noticed that I failed to read the instruction
properly and gave a dose which was almost five times higher than the
usual dose.
2. Feelings: I was very afraid and nervous after I realized the mistake I had
done. However, as this was my first encounter with such medication
errors, I was clueless regarding the best course of action. This experience

NRSG367 ASSESSMENT 2 REFLECTION 3
relates with the medication safety standard of NSQHS as it violates the
responsibility to prioritize medication reviews and minimize risk of
medication problems for patient (ACSQHC, 2017).
3. Evaluation : After I realized the medication dosage errors, I was in two
minds regarding reporting of the adverse event to other staffs. However,
as maintaining well-being of patient and promoting their safety was an
important responsibility for me as a nurse (Flynn et al., 2016; NMBA,
2016), I took the decision to immediately report about the adverse event
without worrying about the impact this will have on my own practice. The
positive thing was that I decided to report about the adverse event and this
was in relevance the NSQHS medication safety standards as it states that
health care organization must have process to document adverse reaction
(ACSQHC, 2017). The negative thing was that I failed to adequately
complete the five rights of medication administration process thus leading
to the mistake.
4. Analysis : From this experience, I learnt about the significance of
medication review element mentioned in the NSQHS standard. The
standards mentioned about using best practice during medication review.
However, the mistake I did was that failed to complete the five rights of
medication administration process accurately. One of the right is right
dose and it involves double checking the medication order and checking
the label of the drug. However, I failed to double check the drugs and
dosage leading to the errors (Martyn, Paliadelis & Perry, 2019). From this,