Human Error in Nursing Practice: Consequences and Developing Nursing Action Plan

This essay discusses the consequences of human error in nursing practice and the need for developing a nursing action plan. It includes a case study of a medication error that led to the death of a newborn and reflection on the incident. The essay emphasizes the importance of following proper procedures and ensuring the quality of healthcare services.

Individual Essay

Table of Contents
INTRODUCTION...........................................................................................................................3
MAIN BODY...................................................................................................................................3
Description of nursing incident...................................................................................................3
Consequences of incident............................................................................................................4
Developing nursing action plan..................................................................................................4
Reflection....................................................................................................................................4
CONCLUSION................................................................................................................................5
REFERENCES................................................................................................................................6

INTRODUCTION
Nursing role is highly important in within healthcare. This allows individual to get better
and effective care which is needed for the better and improved health. Patient believe in their
healthcare professional, so, healthcare professional have the responsibility to take care of their
patient effectively. In this essay there is discussion about the human error in nursing practice and
its consequences which lead to impact the patient life. There is also discussion about the nurse
role that can impact the patient health. This essay also consist the information which is regarding
nursing practice through some basic plan. There is fault of nursing staff where medication for
Sarah Hassan was morphine 10mg and given medication was 100mg. Due to fault of medication
there was death or baby. This happens due to lack of precise practice and such type of nursing
practice should not happen in future. In this is about delivery and practising effective within
healthcare. This is important for the better health and safety for patient (Karttunen & et. al.,
2020).
MAIN BODY
Description of nursing incident
According to Nicolas Perpitch (2021), there was a pregnant lady Mrs Sarah Hassan who
got the wrong dose of morphine which was about ten times highly than the prescribed dose. This
was the fault of the nursing staff or midwives who was taking care of Mrs. Hassan. Due to
human error there is given dose of morphine was 100 mg instead of 10 mg. This lead to overdose
of the medication and lead to cause of come. Mrs. Hassan went to coma and due to overdose
born child was dead and body was heat due to reaction of morphine due to higher dose. This was
one of the example of bad practices within nursing. There was need to improve the practice
which can help to avoid such type of misleading of medication through the any healthcare
professionals. Investigation was occurred and termination for the nursing staff was there. But this
could not change the sorrow of Mrs. Hassan. Nurse role was to take care of Mrs. Hassan and her
time to time medication and others. Nursing staff should have careful during delivery of
medication to her. If nursing staff has been careful regarding this, then such incident could not
have happened (Griffin & et. al., 2019).

Consequences of incident
Due to this incident, there was the consequences which was there to the nursing staff and
the family or Mrs. Hassan and his husband. Due to this, incident of giving higher dose of
morphine lead to take Mrs. Hassan to the coma. This was the first consequence to Mrs. Hassan
then due to higher dose there was impact on the child which was there in Mrs. Hassan and due to
reaction baby get died and this was the major consequence of this incident to the Mrs. Hassan
family. Due to this consequence, investigation has been ordered through child mortality
committee. This was effective and in response midwife registration was suspended by the
Australian Health Practitioner Regulation Agency. Another staff member has resigned. This
impact the nursing staff and the Mrs. Hassan family (Ambwani & et. al., 2019).
Developing nursing action plan
There is need to develop the nursing action plan which can be highly effective and allow
to follow the nursing process. This can allow to follow procedure that can allow to describe the
nursing actions. This allow nursing staff about the procedure and other to follow that can help to
describe the action for the appropriate nursing practice. This is effective for the patient and the
nursing staff. This focus on the implementation of treatment, teaching movement and procedures
that can help to improve the patient comfort and their health. There is need to follow all the
procedure and other action that can allow to good practices within healthcare. Diagnosis and
treatment procedure should clear enough to get easily understand by the nursing staff. There is
need to focus on the delivery of better training for implementing better practices. This practices
can be highly helpful for the preventing such type of incident in future (Tan & Fu, 2020).
Reflection
After getting this incident I feel very sorry for Mrs. Hassan and for her family. I was
shocked that how it can be possible to neglect and for this error. I feel that there is big mistake
occur by the nursing staff because during medication, it is crucial to focus on the doses of the
medication. This incident tells that nurse should have keep focus during practice and should not
have made such type of big mistake that can lead to risk of life. According to me nurse have been
thinking about their personal issues or may be there nurse have some other focus on their work.
Nurse could have learned the lesson that every care is highly important and should not take any
action lightly. There could be chance of higher consequences due to small neglect. There is need
to get ensure about the prescribed medicine when needs to administered to patient. There is also

need to get ensure about the dose and to follow the safe practices while handling and delivering
care to patient (Chen & et. al., 2020).
CONCLUSION
From the above discussion, it can be conclude that while delivering service to patient or
any client within healthcare, there is need to get ensure about the quality of services and the
proper dose of medication. This can impact on someone life directly and can change life due to
any fault of neglect. In this, there is case of neglect through the nursing staff which lead to cause
of death for the new born baby. There is need to take care while delivering healthcare services.
There is also need to ensure about the dose and medication which can impact individual life.
This essay includes the description of the incident and the cause of this incident. This essay also
consist of nursing action plan which can help to reduce such type of incident in future.

REFERENCES
Books and Journals
Ambwani, S., Misra, A. K., & Kumar, R. (2019). Medication errors: Is it the hidden part of the
submerged iceberg in our health-care system?. International Journal of Applied and
Basic Medical Research, 9(3), 135.
Chen, H. T., Morosanu, L., Bellury, L. M., & Kimble, L. (2020). Multiwave formative
evaluation of a retention program for minority nursing students: Intended effects,
unintended consequences, and remedial actions. American Journal of Evaluation, 41(1),
71-88.
Griffin, B. R., Thomson, A., Yoder, M., Francis, I., Ambruso, S., Bregman, A., ... & Jalal, D.
(2019). Continuous renal replacement therapy dosing in critically ill patients: A quality
improvement initiative. American Journal of Kidney Diseases, 74(6), 727-735.
Karttunen, M., Sneck, S., Jokelainen, J., & Elo, S. (2020). Nurses’ self‐assessments of adherence
to guidelines on safe medication preparation and administration in long‐term elderly
care. Scandinavian journal of caring sciences, 34(1), 108-117.
Fu, Y., Tan, M., & Fu, M. (2020). Effect of Multi-Directional Nursing Intervention on the
Prognosis and Quality Of Life in Patients with Type 2 Diabetes. Indian Journal of
Pharmaceutical Sciences, 110-116.