Reflective Essay: Medication Error and NSQHS Standards in Nursing

This report is a reflective essay by a nursing student, analyzing a medication error incident that occurred in a maternity ward. The reflection utilizes the 5 R's framework (Reporting, Responding, Relating, Reasoning, and Reconstructing) to explore the incident's impact on the student's understanding of nursing practice. The essay critically examines the incident in relation to the National Safety and Quality Health Service (NSQHS) standards, specifically the Medication Safety and Clinical Governance standards. The student discusses the error, their emotional and professional responses, and the theoretical underpinnings of nursing ethics and medication safety protocols. The report highlights the importance of vigilance, clinical governance, and adherence to NSQHS standards to prevent future medication errors and ensure patient safety. The student also reflects on the need for continuous learning, incident reporting, and organizational commitment to clinical governance principles, referencing relevant literature to support their analysis.

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

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clinical governance of responsibility. Hence, occurrence of a medication error straightaway
indicates towards poor clinical governance.
Reasoning
Although, I have mentioned that, I was busy with some other patient, when I should
have been assisting the nurse, but this was due to the fact that there were less number of
nurses during the shift and the workload had been high, each of the nurses might have to look
after more than one patient at a time. This indicates towards a poor clinical governance.
According to the NSQSH standard, it is important that the health service organisation can
identify the organisational by performing risk assessments, such that issues like shortage of
staffing, proper documentation and prompt reporting of the incidents are made (NSQSH,
2017). Being a nurse, I am well aware of the different procedures about the risk assessment.
Hence, it is necessary to monitor that the other health care staffs also abide by the same.
Drug administration can be considered as the highest risk areas, and is a matter of
concern for both the nurses and the managers. As per the Consumer Protection Act 1987 and
the Medicine act 1968, the practitioners have the right to ensure that correct medication is
given to the patients at the right time, right dosage and the correct route of administration
(Daly et al., 2017). Such an incident has highlighted the need for a vigilance and high clinical
governance in a health care settings.
Reconstructing
As already been discussed, that medication administration is an important part of the
midwives role. The drug error has been costly in terms of an increased stay in hospital. In
regards to the reporting of the drug errors, several concerns have been emerged, including the
confusion of nurses regarding the prompt actions that needs to be taken (Daly et al., 2016).
From the experience, I have learnt a valuable lesson and I will ensure that I will be alert and

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mindful, while medication is being administered and will also be watchful, that mistakes are
not repeated. I will ensure to maintain documentation and incident reports for medical errors
and will also escalate after repeated intimations. I intend to indulge in lifelong learning such
that I remain updated with the current standards. This will not only make me alert but will
also increase my clinical reasoning and the critical thinking skills. I will ensure that the
organisation, in which we work abides by the seven pillars of clinical governance, like
clinical effectiveness, risk management, experience of patient, communication, resources
effectiveness, learning effectiveness and strategic effectiveness. This incident would serve as
a learning curve, which will help me to increase my further professional practice.
Conclusion
In conclusion, it can be said that drug administration is an important part of clinical
governance, which required competence and ample knowledge about the correct dosage.
Pharmacokinetics and their contraindications. The NSQHS standards acts as an ideal
framework that contains guidelines for the nurses for proper administration of medicines.
Furthermore, it is the duty of the nurses to review the dosage of administrations with the
medication chart of the patient. Nurses should be more mindful during their practice.

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References
Daly, J., Jackson, D., Mannix, J., Davidson, P. M., & Hutchinson, M. (2014). The importance
of clinical leadership in the hospital setting. Journal of Healthcare Leadership, 6, 75-
83.
Hesselgreaves, H., Watson, A., Crawford, A., Lough, M., & Bowie, P. (2013). Medication
safety: using incident data analysis and clinical focus groups to inform educational
needs. Journal of evaluation in Clinical Practice, 19(1), 30-38.
Kavanagh, C. (2017). Medication governance: preventing errors and promoting patient
safety. British Journal of Nursing, 26(3), 159-165.
Kavanagh, C. (2017). Medication governance: preventing errors and promoting patient
safety. British Journal of Nursing, 26(3), 159-165.
Kellett, P., & Gottwald, M. (2015). Double-checking high-risk medications in acute settings:
a safer process. Nursing Management, 21(9).
NSQSH, (2017).Clinical Governance Standard. Access date: 5.8.2019 .Retrieved from:
https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-
Quality-Health-Service-Standards-second-edition.pdf