NRSG367 Assessment 2 Reflection: Patient Safety and Quality Care

This report provides a critical reflection on a nursing student's clinical practice, focusing on two National Safety and Quality Health Service (NSQHS) standards: medication safety and communication for safety. The student recounts an experience involving a medication error, analyzing their feelings, evaluation of the situation, and actions taken. The reflection delves into the importance of adhering to best practice guidelines, including the five rights of medication administration and timely reporting of adverse events, as highlighted by relevant literature. The report also examines communication breakdowns and their impact on patient safety, emphasizing the need for effective information sharing within healthcare teams. The student outlines an action plan for future scenarios, emphasizing the need for double-checking medication dosages, avoiding interruptions, and improving communication strategies to enhance patient outcomes and adhere to NSQHS standards. The assignment references several research articles and guidelines to support the reflection and analysis.

Running head: NRSG367 ASSESSMENT 2 REFLECTION
1
Title page
Student Name:
Semester 1, 2020
Word count:

NRSG367 ASSESSMENT 2 REFLECTION 2
Introduction:
The paper will give a critical reflection on a past clinical practice experience and
relate those experience to one or two of the NSQHS (National Safety and Quality Health
Service Standard) standards. This form of reflective exercise will help to determine how
the clinical experience helped in developing knowledge related to patient safety and
enhancing the quality of care.
Standard
1. Description The standard chosen is medication safety standard which
lays down the procedure needed to reduce adverse medication events
and improve safety and quality of medication use. Clinical governance,
correct documentation, continuity of medication management and
adherence to best practice related to administration of medication are
some of the elements of this standard (Australian Commission on Safety
and Quality in Health Care (ACSQHC), 2017). During my clinical
experience, I was involved in providing care to a 67 year patient who
came to the ward after a knee surgery. As per the handover instruction, I
was supposed to administer an analgesic to patient. However, after I
prepared the medication, I noticed that I failed to read the instruction
properly and gave a dose which was almost five times higher than the
usual dose.
2. Feelings: I was very afraid and nervous after I realized the mistake I had
done. However, as this was my first encounter with such medication

NRSG367 ASSESSMENT 2 REFLECTION 3
errors, I was clueless regarding the best course of action. This experience
relates with the medication safety standard of NSQHS as it violates the
responsibility to prioritize medication reviews and minimize risk of
medication problems for patient (ACSQHC, 2017).
3. Evaluation : After I realized the medication dosage errors, I was in two
minds regarding reporting of the adverse event to other staffs. However,
as maintaining well-being of patient and promoting their safety was an
important responsibility for me as a nurse (Flynn et al., 2016; NMBA,
2016), I took the decision to immediately report about the adverse event
without worrying about the impact this will have on my own practice. The
positive thing was that I decided to report about the adverse event and this
was in relevance the NSQHS medication safety standards as it states that
health care organization must have process to document adverse reaction
(ACSQHC, 2017). The negative thing was that I failed to adequately
complete the five rights of medication administration process thus leading
to the mistake.
4. Analysis : From this experience, I learnt about the significance of
medication review element mentioned in the NSQHS standard. The
standards mentioned about using best practice during medication review.
However, the mistake I did was that failed to complete the five rights of
medication administration process accurately. One of the right is right
dose and it involves double checking the medication order and checking
the label of the drug. However, I failed to double check the drugs and

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dosage leading to the errors (Martyn, Paliadelis & Perry, 2019). From this,
I learnt about the significance of best practice guidelines in medication
administration. In addition, timely reporting about the adverse events
made it possible for senior nurse staffs to intervene and give antidote to
overcome the high dosage affect. This experience revealed the
significance of adverse event reporting. Duarte et al. (2015) argues that
fear of punishment often deters nurse from reporting about adverse
events. However, the article mentions the need for nurse to understand
the errors can be handled in a positive way by timely reporting about it.
5. Conclusion: From the experience, I can be concluded that adhering to
best practice standards is crucial to promote medication safety in nursing
practice
6. Action plan: Through this experience, I have learnt that if places with
similar situation again, I will avoid any interruptions during the medication
administration process and double check the dose given to patient.
Standard 2:
1. Description During the clinical situation of dosage related error, I took the
decision to immediately consult my medical team. I firstly communicated
with the most immediate nurse who was near to me. However, after
realizing that the nurse was not in a position to handle the issue, I decided
to communicate about the issue to the nursing leader. This experience
relates with the ‘communicating for safety’ NSQHS standard as I followed

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the system to effectively communicate critical information and risk to
ensure safe patient care (ACSQHC, 2017).
2. Feelings: During that time, I was having the fear that I will be suspended
from my practice for the mistake. However, I realized that suspension
could be for a temporary period and if I do not communicate about the
issue, it could cost patient life. Thus, I decided to contact my
interdisciplinary team. This is related to the chosen standard as it signifies
the benefit of critical information sharing in clinical practice.
3. Evaluation : The positive thing about the experience was that immediate
communication helped to resolve the issue as senior nurses intervened
and they were able to control an adverse event. However, the negative
part was that deciding to report about the risk was difficult due to lack of
such safety culture. In future, my priority will be to effectively communicate
particularly during the handover process.
4. Analysis : From the clinical experience, I learnt about the benefits of
clinical communication process during high risk situation. The best
practice as per this NSQHS standard is to communicate about any risk in
a timely manner. Vermeir et al. (2015) argues that poor sharing of
information lead to adverse events and subsequent patient harm. This
compromises patient safety as right information is not available to the right
person at the right time. Thus, active sharing of such information can
ensure that right person is present to handle or overcome the issue.

NRSG367 ASSESSMENT 2 REFLECTION 6
Merlino (2017) linked effective communication to better patient outcome,
decreased adverse event and shorter length of hospital stay.
5. Conclusion: Through the experience, it can be concluded that all nurse
must be aware of organizational process to immediately communicate
regarding high risk situations and the authorities to contact in case of such
situation.
6. Action plan : As the process of getting help from the right staff was
delayed for sometime because of taking time to approach staffs one by
one, I have planned to contact the leader and be aware about systems to
immediately report and communicate about any risks related situation that
could affect patient outcome.
Conclusion:
From the above critical reflection, it can be concluded that adhering to best
practice guidelines for medication administration is crucial to avoid risk and promote
better outcome for patient. In addition, the reflection also gives lessons regarding the
clinical benefit of timely reporting about any dosage or nursing practice errors instead of
fearing about the negative professional consequences of the action.

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References
Australian Commission on Safety and Quality in Health Care. (2017). National Safety
and Quality Health Service Standards (2nd ed.). Sydney: ACSQHC. Retrieved
from https://www.safetyandquality.gov.au/sites/default/files/2019- 04/National-
Safety-and-Quality-Health-Service-Standardssecond-edition.pdf
Duarte, S. D. C. M., Stipp, M. A. C., Silva, M. M. D., & Oliveira, F. T. D. (2015). Adverse
events and safety in nursing care. Revista brasileira de enfermagem, 68(1), 144-
154.
Flynn, F., Evanish, J. Q., Fernald, J. M., Hutchinson, D. E., & Lefaiver, C. (2016).
Progressive care nurses improving patient safety by limiting interruptions during
medication administration. Critical Care Nurse, 36(4), 19-35.
Martyn, J. A., Paliadelis, P., & Perry, C. (2019). The safe administration of medication:
Nursing behaviours beyond the five-rights. Nurse education in practice, 37, 109-
114.
Merlino, J. (2017). Communication: A critical healthcare competency. Patient Saf. Qual.
HealthCare.
Nursing and Midwifery Board of Australia (NMBA) (2016). Registered nurses
STANDARDS FOR PRACTICE. Retrieved from:
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/
Professional-standards.aspx
Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., ... &
Vogelaers, D. (2015). Communication in healthcare: a narrative review of the

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literature and practical recommendations. International journal of clinical
practice, 69(11), 1257-1267.