Reflective Essay on NSQHS Medication Safety Standard and Clinical Governance Standard

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

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Reflective essay
The development of the NSQHS standard has been designed as a framework for the
promotion of safety and quality of the Australian health care system. In this paper, I will
reflect on an incident that occurred at the time of a shift on the maternity ward. In order to
reflect on my clinical experience, I have taken up 5 R’s of reflection. This tool assists
students to reflect on their professional practice. This reflection is in regards to the NSQHS
Medication safety standard and clinical governance standard.
Reporting
The incident is related to the administration of wrong opiate drugs to the patient, who
had been in the postpartum period. This incident occurred during the checking and the
administration of the controlled drug. The drug error was discovered by the medical
coordinator, during the shift handover (Kavanagh, 2017). During the daily checking of the
dosage drugs, the coordinator and a midwife found a discrepancy in the number of ampules
of Morphine. There was too many morphine ampules and too few morphine ampules. I was
assisting the nurse, who administered a wrong medicine, although I was attending another
patient at that time. I was surprised to find that this matter was not escalated to the higher
authorities.
Responding
When I was being informed about the incident, my initial reaction was of horror and
disbelief and it was hard to believe that, such a mishap took place, while I was present in the
ward and I had always cross checked medicine before administering them to the patient. I
was confused, and at the same time angry, as my peer nurse never makes such errors ad since
I had been assisting her, a part of accountability also lies with me. My feeling was of

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embarrassment, as I had never committed such a gross mistake. I felt ashamed that, instead of
assisting this nurse, I was busy with some other work.
Relating
I am well aware of the theoretical underpinnings of the nursing codes of ethics, which
states that nurses are liable to provide a high quality of care to the patients. It was our luck
that no serious harm was caused to the patients. But, I am aware of the fat, that medication
errors can be serious occasionally and can lead to life threatening conditions, often causing
adverse drug reactions and even death. I was feeling extremely ashamed since, I had received
ample education regarding the five rights of medication error like ineffective prescribing,
under prescribing, wrong dosage of prescriptions, wrong duration, wrong patents, and wrong
label. Hence, whenever, I administer medications, I make sure that, I don’t repeat these
mistakes.
Reflecting on the mistakes, I ensure, that I should be alert while administering
medications and will also keep an eye on my peers, that such mistakes are not repeated in
future. It is important to detect the medication errors as system failures that results in minor
errors can later on lead to more severe errors (Hesselgreaves et al., 2016). Reporting of the
errors has to be encouraged by the creation of a blame and a non-punitive environment.
Errors in prescription of the data includes irrational, ineffective prescribing of medicines
(Kellett & Gottwald, 2015). I am well aware of NSQHS standard which ensures that
clinicians are competent enough for prescribing, dispensing and administering appropriate
medications, medicine documentation and medication management procedure (NSQSH,
2017). This incident has indicated towards the fact that a strong vigilance is required to avoid
such drug errors in maternity wards. Medication management is a significant part of the