Assignment on Performing Medication Review

Running head: NRSG367 ASSESSMENT 2 REFLECTION
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Semester 1, 2020
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NRSG367 ASSESSMENT 2 REFLECTION 2
Performing medication review for patients and adhering to best practice is one of
the National Safety and Quality Health Service Standard that all nurses must adhere to
during daily practice. It highlights the need to prioritize medication reviews and minimize
risk of medication related problems during medication management (Australian
Commission on Safety and Quality in Health Care (ACSQHC), 2017). However, nurse
often fail to comply with all the rights of medication administration and I will give a
critical reflection on similar experience that I encountered during my clinical placement.
During my clinical placement in a cardiac ward, there were two patients with
similar names. After handover, a night shift nurse asked my buddy nurse to give
oxycodone to a patient. However, the issue that took place was that my buddy nurse
gave the medication to another patient with a similar name. She ignored the medication
chart of the patient which said that patient was allergic to oxycodone. Within 15-20
minutes, the patient pressed the emergency bell and I had to attend to the patient as my
buddy nurse was not available. The patient was breathless and drowsy. As the buddy
nurse was busy with other doctor, I thought of the need to consult the nurse-in charge
as I could sense the situation needed immediate medical attention. I contact the RNIC
and the patient condition was managed after the met team arrived and they provided
respiratory support using advanced medical equipment. This issue is a case of
inappropriate completion of medication review and poor responsibility in completing the
nine rights of the medication administration process.
After the visiting the patient after emergency bell, I could sense that something
was extremely wrong as patient was finding it hard to breath and she was too drowsy to
speak. On reviewing the medication chart, I realized that the buddy nurse had given

NRSG367 ASSESSMENT 2 REFLECTION 3
medication to the wrong patient. This clinical situation is linked to medication safety
standard of NSQHS as the nurse displayed incompetency to appropriately administer
medicines to patient.
After reviewing the medication chart and assessing the last medication given, I
realized that my buddy nurse had made one major mistake. She gave oxycodone to the
wrong patient. This mistake occurred because she failed to follow the seven rights of
medication administration. The NSQHS standards of medication safety states the need
to reduce risk of medication related errors by effective medication review (ACSQHC,
2017) and following the seven rights to medication administration is one of the step to
safe medication administration (Smeulers et al. 2015)- The best practice to identify right
patient during medication administration includes looking for at least two patient
identifiers before giving medication to any patient. This may include reviewing patient’s
full name and medical identification number (Zakria & Mohamed, 2017). However, the
buddy nurse failed to complete this right as it is evident that she did not cross-checked
the medication order prescribed with that of the medical identification number. This
action of the nurse is in violation of the NSQHS medication safety standard. Although
other rights like right dose, right time, right route and right documentation was
maintained. However, by making mistakes in identifying right patient, the buddy nurse
created a very threatening situation for patient.
On critical review of the situation, I became aware of the consequences of not
following best practice in medication safety. Due to lack of steps taken to confirm
identity of patient, oxycodone was given to the wrong patient. The situation became
more chaotic as the patient receiving the drug was allergic to the it. During the use of