Nursing Incident Report: Medication Error and Reflection

This report analyzes a critical incident involving a medication error in a nursing setting, specifically focusing on the death of an elderly patient due to the improper administration of medication. The analysis delves into the incident description, highlighting the nurse's lack of critical thinking and adherence to established protocols. It examines the immediate and broader consequences, including ethical conflicts related to beneficence and non-maleficence, and the exposure of gaps in healthcare settings. The report proposes a detailed nursing action plan, emphasizing the importance of seeking senior advice, adhering to NMBA and ACQSH standards, and incorporating patient safety and quality training. It also includes a personal reflection from the student, utilizing Rolfe et al.'s reflective model to assess the incident's impact and identify areas for improvement in future nursing practice. The report concludes with a call for enhanced patient advocacy and adherence to evidence-based care planning.

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

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Introduction
The term critical reflection can be defined as a fundamental component of clinical
nursing practice that possess the potential to impact booth personal as well as professional
development of an individual. Critical reflection can be used as a method or tool that connects
experiences with methods. Nurses, by implementing the process of critical reflection develop self
awareness that helps them to review as well as improve their clinical skills. As being
recommended by Nursing and Midwifery Board of Australia Standard 1 and 2, critical reflection
in nursing involves incorporation of evidenced based research as well as supervision from senior
colleagues in nursing interventions (Rolfe, Freshwater, Jasper, 2001). In this essay, a detailed
discussion and analysis on the medication error of a nurse and on the importance of the role of a
nursing action plan and personal reflection for future improvement has been performed.
Discussion
Description of the incident
An elderly patient aged 97 years has lost her life after a nurse named Lopez administered cursed
powders of tablet in her saline. This incite demonstrate clear lack critical thinking and reflection.
According to researchers, medical malpractice can be the result of several factors. However, the
prime cause associated with medical malpractice includes medical negligence resulting in
medication error.
The incident took place after the elderly patient demonstrated difficulty in swallowing her oral
medication. In order to provide her with the medication, the accused nurse powdered the
medication and injected the same intravenously. This act, along with the demonstration of lack of
critical thinking also demonstrated that the nurse have proceeded without any king of

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communication as well a supervision of the seniors. According to Pai et al., (2017)., the
professional interpersonal communication needs to be adhered for obtaining a credible second
opinion which is directed to the best interest of the patient. It is highly crucial for nurses to
reflect their action since it provides scope for rectification (Snowdon et al., 2017). The above
discussed incident clearly demonstrates, the importance of critical thinking as well as nursing
reflection in the prevention of adverse consequences of the heath care service users, families as
well as organizations (Schuelke & Barnason, 2017).
Consequences of the Incident
The immediate consequences of administering inappropriate medication have result in the
death of the healthcare service user. According to Ortiz, (2018), lack of adherence to the
evidence base practice, critical reflection as well as thinking by the healthcare service providers
often result in loss of trust of the patients as well as their families and even death of the patients.
It can be argued that the action of Lopez, has conducted the act out of empathy to the patient
since she was unable to swallow her medication (Feleke, Mulatu & Yesmaw, 2015). However,
this act of empathy has lead to ethical conflict along with beneficence and non-maleficence
(ACQSH, 2017). According to International Council of Nurses, (2012), nurses possess ethical
obligation of managing and preventing if possible, medical errors. As per the standard 1 of the
NMBA (2016), it is highly crucial for nurses to engage in the pratie that is critical, person
centred evidence based and safe in collaboration with personal reflection (NMBA, 2016). Thus
Lopez is subjected to ethical confrontation of beneficence and non-maleficence since she failed
to balance the possible risks and the benefits associated with her act.

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Another consequence of the incident includes exposure of the gap of heath care home settings.
As per the Medication Safety Standard 4 of ACQSH (2012), it is highly crucial for the
healthcare professionals to conduct medication assessments, prepare medication lists, medical
history of the patient as we as educate the patient on the same. However since this action has not
been conducted, lack of competence and knowledge of the heath care service provider is clearly
evident.
Nursing Action Plan
It can be clearly understood that Mavis Lopez should eek advice form her seniors before
conducting the act of medical malpractice. In case of unavailability of the physicians, advice
could be taken from the Senior Registered Nurses.
As per the Standard 5 of NMBA (2016), it is highly crucial for nurses to engage in the
development and implementation of nursing plan associated with professional practices. In order
to prevent the incident described above, nurses needs to engage in evidence care keeping
accordance to the standards of ACQSH (2017). In order to deliver a high quality care to the heath
care service users along with holistic recovery, a nursing action plan that includes nursing goals
in alignment with the best available sources of evidence must be performed. The mentioned
nursing plan can also include the ACQSH (2017) standards of safety and quality training
(ACQSH, 2012). In order to prevent medication error, nurses needs to ensure appropriate
evaluation of the health and medication records of the patient along with the documents before
implementing interventions. A professional action plan of nurses should include association with
ACQSH (2017) patient safety and quality standards of procedures and policies. This will ensure
deliverance of safe evidence based care. Lastly, the action plan for nurses should include

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compliance with the ethical practice as per the Code of Ethics by the Iinternational Council of
Nurses.
Personal Reflection
The scenario prompted me for reflecting my feelings as a medical student. In the following
paragraph, I reflected on the incident by using the Rolfe et al's reflective model.
What
I strongly felt that the medical negligence have resulted in the above discussed scenario. I felt
lack of communication and knowledge was also associated with the act of Mavis Lopez.
So what
As per my opinion, the scenario pointed out the gap of appropriate medical practice amongst
nurses. I also understood the importance of developing comprehensive skill set.
Now What
I felt that it is highly crucial to incorporate an effective nursing action plan in order to prevent
such scenarios. As a future nurse I plan to abide by all the NMSBA standards.
Conclusion
From the above discussed situation, the gap in the care of the nurse was clearly evident.
The aspect associated with the advocacy of the patient that needs to be deeply engraved in the
nursing practice is missing. The importance of an effective care giving plan for nurses with
adherence of the NMSBA is clearly evident.

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Reference List
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Feleke, S. A., Mulatu, M. A., & Yesmaw, Y. S. (2015). Medication administration error:
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