Critical Analysis of Nursing Incident: Medication Error and Reflection

This essay provides a critical analysis of a nursing incident involving a medication error that resulted in the death of an elderly patient. The incident involved a nurse, Ms. Lopez, who administered crushed oral medication intravenously, violating nursing standards and leading to the patient's death due t...Read More

Running head: NURSING PRACTICE
NURSING PRACTICE
Name of Student:
Name of University:
Author’s Note:

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The critical reflection on nursing incident is the new approach, through which nurse are
capable are to give effective care to the patient and family and minimizes the risk of any medical
error. Therefore, the main aim of the essay is to evaluate and critically analyse the nursing
incident depicting the medication error, which has caused death of the elderly patient. The major
reason behind such shortcoming in practice is lack of awareness of evidences based practice and
nursing practice standards of National Safety and Quality Health Service Standards. The
National and Midwifery Board of Australia gives nurse ways towards healthy and ethical
practice and set boundary for their actions. The essay will discuss about the area where the nurse
need to be conscious to improvise their practice. The main goal of the essay is to make the nurse
knowledgeable about the evidence based practice and critical reflection on the nursing scenario
in order to make them competent to provide safety environment for the patient and give reliable
care for faster recovery.
The ignorance by the nurse towards healthy practice can have lethal consequence to the
health of the patient. The incident described showed unethical and unprofessional practice by the
nurse named Ms Lopez, due to which the patient named Mrs Anderson of 97 years old died
(Bibby, 2019). The patient was admitted because of complain of UTI, vomiting and nausea. She
was having healthy recovery and was supposed to be discharged in few days. However, she was
having issue in swallowing, and the nurse in-charge in care of Mrs Anderson, crushed three oral
medicine and administered via IV route in the right arm and additionally she did not consulted to
any senior registered nurse for right route for medication. Later with time, the patient had huge
pain in left arm and wrist, which was sign of heart attack, and consequently caused death.
According to the International Council of Nurse (ICN), code of ethics 2, (2015) nurse need to be

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assertive and consult the senior nurse prior to any action taken in care of patient. For violation of
standards, Ms Lopez was charged for the manslaughter by legislative.
The impact of ignorance by the nurse are endure by the patient and their family.
According to Nursing And Midwifery Board of Australia, code of ethics, 5, nurse are supposed
to value the informed decision making before giving any treatment to the patient (Nursing
Midwifery Board of Council, 2016). As per the medication standard four highlighting medication
safety, it is the legal duty of nurse to ensure the dose for medication, its risks and route of
administration (National Safety and Quality Health Service, 2019). Any violation of such
standards and codes by the nurse can involve them in legal charges. According to Nursing
Midwifery Board of Council (2016), nurses who are found guilty of misconduct in their
professional practice, shall be reliable for the cancellation for their registration. Therefore, in the
case study, lack of idea about the evidence based practice by the nurse and caused the nurse to
administer wrong way of medication that caused death of the patient. Hence, as the consequence,
the both patient and nurse suffer the negative impact.
There is the requirement for minimizing the medical error by the nurse and making them
aware about evidence based practice and standards for patient safety. Hence, for such there is the
need of effective action plan, which will help in lowering such unethical practice, are described
as follow. First, nurses can get education and involve in course to learn about the ethical practice
and standards by Australian Commission on Safety and Quality in health Care (2017). Second,
the nurse can get training where they can have get practical experience in evidence based
practice (Longhurst, 2016). Third, rule should be made where enrolled nurses must consult to the
senior registered nurse before giving any treatment or medication to the patient. It is evident
from the study of Warren et al. (2016) clinical registered nurse have leadership quality to

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supervise the unexperienced nurse to make them competent to give safe care. Fourth, enrolled
nurse can be given training and education for administration of medication and in practice if they
encounter any issue with the task, they need to report to the RN (Nursing Midwifery Board of
Australia, 2015). It is depicted in the case study that RN was not aware about the patient’s
inability to swallow medication, as it was not communicated by the EN. As per the NMBA
standard for RN, fifth action plan would be for RN to make a comprehensive assessment of
patient and provide adequate way for medication to the EN (Nursing Midwifery Board of
Australia, 2015). In the case study, the RN should have changed the route of administration from
IV to IMI for faster recovery. Hence, above-mentioned action plan can help to make the EN
capable to give effective care and ware about evidence based practice.
Reflection of the incident is based on the Rolfe model (Rolfe, Freshwater & Jasper, 2001)
that describes the learning from the case scenario.
The incident has given me insight about the importance of healthy practice by the nurse
as any negligence from there end can cause lethal consequence to the patient. I also felt lament
for the patient and their family. I also felt that nurse role is of high importance for safety of
patient.
I think that the action by the nurse was not appropriate; she violated the nursing principle
and standards. She might be feeling guilty for her action and wishing she would have reported
the complication to the RN before giving medication.
Now I think nurse will become more conscious towards their work and responsibility and
will remember about the standards and ethical principle of nursing. Further, nurse need to be
knowledgeable about the evidence based practice and should implement it in their daily practice.

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Lastly, from the above discussion, it can be concluded that nurses are the responsible
body to give effective care to the patient and should follow practice guideline in their action.
Any ignorance can cause harmful impact to the patient as well as they may face legal obligation
for it. The error in medication can happen because of lack of awareness of critical analysis and
evidence based practice. Therefore, there is the need for the nurse to become competent enough
to provide safety to the patient.

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Reference
Australian Commission on Safety and Quality in health Care . (2019). Medication Safety
Standard | Australia Commission on Safety and Quality in Healthcare. Retrieved 18
August 2019, from
https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-
standard
Bibby, P. (February 22, 2015). Sydney grandmother who died after nurse's error was already 'at
death's door', court hears. Retrieved 18 August 2019, from
https://www.smh.com.au/national/sydney-grandmother-who-died-after-nurses-error-was-
already-at-deaths-door-court-hears-20150222-13lim1.html
International Council for Nurses, Code of Ethics. (2015). Retrieved 18 August 2019, from
https://www.icn.ch/sites/default/files/inlinefiles/2012_ICN_Codeofethicsfornurses_
%20eng.pdf
Longhurst, C. (2016). Leadership and efficiency--chief nurse's vision for better
outcomes. Nursing Standard, 30(39).
National Safety and Quality Health Service Standards. (2019). National Safety and Quality
Health Service Standards. Retrieved 6 August 2019, from
https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-
Quality-Health-Service-Standards-second-edition.pdf
National and Midwifery Board of Australia. (2016). Nursing and Midwifery Board of Australia -
Home. Retrieved 6 August 2019, from https://www.nursingmidwiferyboard.gov.au

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Rolfe, G., Freshwater, D., & Jasper, M. (2001). Critical Reflection for Nursing and the Helping
Professions a User's Guide.