Nursing Management and Leadership: Analysis of Medication Error Case Study

This report discusses the application of management concepts in a clinical case study involving medication errors. It analyzes the implications for professional practice and management, and highlights the importance of adhering to the SNB code of ethics and professional conduct.

Running Head: NURSING MANAGEMENT AND LEADERSHIP
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Nursing- management and leadership
11/17/2018

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Contents
Introduction................................................................................................................................2
Description of the Clinical experience.......................................................................................2
Theoretical analysis/Application................................................................................................2
Implications for Professional practice and Management...........................................................4
Conclusion..................................................................................................................................5
References.............................................................................................................................................6

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Introduction
The report brings about the discussion of the nursing assignment which encounters the
description of the management concepts and the aspects of the professional practice in
context to the given case study. The case study will state about the medication error which
takes place in the patient’s care by the nurse and the application of management concepts.
Description of the Clinical experience
The clinical case scenario is the description of the patient Mr Tan, who was looked
after by the nurse after the change was observed in the condition of the patient. The case
described about the wrongdoing or mishandling of the patient’s condition by the nurse as the
patient required several other procedures. The nurse displayed the irresponsive behaviour in
reading the warning of ‘Do not crush’ mentioned on the electronic medication administration
records, impacted the health of the patient. She crushed an extended calcium channel blocker,
and administered it through the Nasogastric tube, which resulted into lowered pulse rate of
the patient. The calcium channel blocker when given to any patient works prevents calcium
to enter the cells of the heart and the blood vessels, which leads to the lowering down of the
blood pressure. Slower heart rate is one of the side-effect of drug which was identified in the
case with Mr Tan, affecting his condition. The case identifies the issue of clinical risk
involved in administration and high risk medication errors committed by the nurse in this
case by crushing of extended calcium channel blocker in NG tube in hurriedness, in clinical
settings (Elliott et al., 2016).
Theoretical analysis/Application
The given case study has led to an analysis that the patient Mr Tan’s health condition
suffered due to the incorrect administration of the medication given to the patient. It has been
known that the occurrence of errors is due to the combination of the human factors and
system factors in the clinical settings. Maintaining quality while eliminating the risk is one of
the major challenges faced by the healthcare and the professionals in undertaking patient
care. In today’s healthcare delivery system, it has been found that the patients have only a one
in two chances of receiving a recommended care for their health condition (Hayes et al.,
2015).

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The research has been undertaken to improve the patient’s care ensuring the patient
safety by delivering them better healthcare services. Therefore, as a leader certain
management concepts that can be effectively applied which would have easily managed the
problem of the patients’ health condition (Miller, Haddad & Phillips, 2016).
Being a leader, I would have provided the nurse and other health profession training
regarding the administration and management of the medications which would ensure the
health and safety of the patient during the time treatment is provided. Leading function of
management is one of the best approaches towards resolving such issues in the healthcare.
The employees or nurses in the healthcare should be guided and motivated by directing them
about the necessary steps to be taken, to provide effective treatments to the patients. The
nurse should acquire knowledge about administering the medications and treatment to be
given to the patients on proper time which would help prevent the occurrence of any
misadventure. Some other management concepts can also be applied in context to the
medication errors in clinical settings, human and systems approach. As in a healthcare
system, active failures are mostly the results of unsafe acts that are committed by the people
or health professionals and inappropriate operating of the systems and tools for the treatment
of patient. The prescribing Information and Communication system (PICS), is one of the
evolving aspect of systems approach which could also prevent and avoid the occurrence of
medication errors, and the issue of risk management in healthcare (Thomas, 2015).
Management concepts which are applicable to the clinical practice include the
management theories, by Henri Fayol, and the Motivational theories by Douglas McGregor to
the clinical case scenarios. Thus, in relation to the case study management functions of
planning, organising, directing, and controlling could have been implemented by the nurse
(Nilsen, 2015). I would have dealt with the poor condition of Mr Tan in way by instructing
the nurses and health managers to prepare an individual care plan to deal with such patients
effectively. As planning is essential in undertaking the patient care, i.e. nurses and other
health professionals, therefore nurses should at first prepare and maintain all the necessary
documents, as they are essential right from the beginning when the patient is admitted in the
hospital till they are finally discharged. It is evidenced from the case, as Mr Tan’s health
condition was the result of poor planning and the wrong drugs being given to the NG tube
inserted into his body, leading to low blood pressure. Thus, as a leader, it is essential to
enforce proper planning, directing the treatment and medications to be given to the patients,

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and controlling their actions which may influence the health condition of the patients
(Barnard, 2017).
In this case, the nurses must firstly enlist the medications required for Mr Tan, who
was patient of nasogastric aspiration, which could have prevented the risk of medication
errors. Healthcare delivery systems can be easily improved only when the nurses are
motivated and encouraged given a positive and healthy environment, leading to minimal
errors. Being a leader it is essential to ensure open flow of communication between the health
professionals, and the nurses so that their issues regarding the work environment may be
resolved. In addition to their administration and management of the clinical practices, the
nurses need to plan, organise, coordinate, and control Tan’s activities and monitor the regular
improvement in his health condition, so that effective care could be delivered to him.
Moreover, Theory Y could have been also implemented to lead such situation and improve
the health condition of Mr Tan (Vaismoradi et al., 2016).
Implications for Professional practice and Management
The above discussion has demonstrated the application of the management concepts
in the clinical case study, which involved description of planning, and implementation of
management to improve the health condition of Mr Tan. Thus, human and systems
approaches to management in the risk management of medication errors in healthcare will
result into certain implications for the professionals in the healthcare to manage such
incidents through their clinical practices. From the assessment of case, medication errors, and
the impact on the health of Mr Tan, I have learned that a nurse leader or doctors in the
healthcare must take care of the prerequisites of giving treatment and care to a patient for the
respective health issue, as it would ensure positive impact on his health (Kerr et al., 2016).
As a leader in healthcare one must evaluate the effectiveness of the patient care,
regularly provide constructive feedback, and training to the team members or nurses so that
they can work together in harmony and assure patient health and safety. The knowledge
acquired from this experience has defined about the responsibilities and accountabilities of a
nurse in the hospital who is to undertake the patient care. Acquiring knowledge and
managing patient care will help one to develop career as a professional nurse in their future,
and attain higher success. Thus, as a novice/beginner from this experience will benefit me by
guiding about ways to develop effective health service plan, to undertake responsibility of

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providing effective treatment to the patients. Becoming a nursing manager I would be able to
analyse the roles and responsibilities to be performed in the clinical practice and attain
positive professional experience (Ginter, Duncan & Swayne, 2018).
SNB code of Ethics and Professional Conduct
Singapore Nursing Board defines and regulates the practice of the nurses and
midwives as stated in the Nurses & Midwives Act. The board establishes various regulatory
standards and guidelines defining about the ethical values, and standards that must be
followed by every nurse in Singapore. The code calls upon the nurses, to ensure and maintain
the reputation of the profession, and comply with the values outlined in the document. They
must follow the 10 value statement towards ensuring effective care of the patient. Nurses
must respect the client or patient’s individual values and needs and inform the patient about
the options available to them to improve their health condition. Thus, nurses in healthcare
must accomplish effective patient care in accordance to the necessary guidelines, and the
professional conduct to help attain positive health outcomes of the patient (Holtrop et al.,
2015).
Conclusion
To conclude the above discussion it has been analysed that management concepts,
that proved to be effective to ensure best treatment to the patients in healthcare. The patients
with a low blood pressure as mentioned in the case study must be given effective care, and
given appropriate medications timely to enhance their health condition.

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References
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successful operation performed at Groote Schuur Hospital, Cape Town. SAMJ: South
African Medical Journal, 107(12), 1271-1274.
Elliott, R. A., Lee, C. Y., Beanland, C., Vakil, K. & Goeman, D. (2016). Medicines
management, medication errors, and adverse medication events in older people
referred to a community nursing service: a retrospective observational study. Drugs-
real world outcomes, 3(1), 13-24.
Ginter, P. M., Duncan, W. J. & Swayne, L. E. (2018). The strategic management of health
care organizations. United States: John Wiley & Sons.
Hayes, C., Jackson, D., Davidson, P. M. & Power, T. (2015). Medication errors in hospitals:
a literature review of disruptions to nursing practice during medication
administration. Journal of clinical nursing, 24(21-22), 3063-3076.
Holtrop, J. S., Potworowski, G., Fitzpatrick, L., Kowalk, A. & Green, L. A. (2015).
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Kerr, D., Klim, S., Kelly, A. M. & McCann, T. (2016). Impact of a modified nursing
handover model for improving nursing care and documentation in the emergency
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Miller, K., Haddad, L. & Phillips, K. D. (2016). Educational strategies for reducing
medication errors committed by student nurses: a literature review. International
Journal of Health Sciences Education, 3(1), 2.
Nilsen, P. (2015). Making sense of implementation theories, models, and
frameworks. Implementation Science, 10(1), 53.
Thomas, T. (2015). Management and leadership for nurse administrators. United States:
Jones & Bartlett Publishers.

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Vaismoradi, M., Griffiths, P., Turunen, H. & Jordan, S. (2016). Transformational leadership
in nursing and medication safety education: a discussion paper. Journal of nursing
management, 24(7), 970-980.