401007 Essay: Analysis of a Nursing Incident and NMBA Standards

This essay provides a detailed reflection on a nursing incident involving a medication error, drawing from a news article. It analyzes the case through the framework of the NMBA (Nursing and Midwifery Board of Australia) Registered Nurse Standards for Practice and the NSQHS (National Safety and Quality Health Service) standards developed by the ACSQHC (Australian Commission for Safety and Quality in Healthcare). The essay explores the ethical and practical implications of the incident, discussing the nurse's breach of duty of care, potential harm to the patient, and the importance of adhering to medication administration protocols. It also incorporates a personal reflection using Rolf's model, outlining the student's understanding of the incident, the lessons learned, and the actions they would take to prevent similar errors in their own practice. The essay emphasizes the need for safe, quality nursing practice, proper communication, and continuous professional development to improve patient outcomes and reduce the risk of medical negligence.

Running head: NURSING REFLECTION
437NURSING REFLECTION
Name of the student:
Name of the University:
Author’s note

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Introduction:
Being front line health professionals, Nurses have a duty of care towards all of their patients who
require medical assistance (Watson, 2015). The duty of care is considered as the obligations
placed on health professionals for acting towards patients according to a certain standard.
Wrong administration of medication is one of the major contributors of morbidity in Australia
where more than 1 million individuals experience it every day (Ingham-Broomfield, 2017). The
case study represents breaching of duty of care of a nurse while she crushed up three different
oral tablets and put them into IV-drip of the patient. In order to provide safe and responsive care
to the patients, the health professionals cannot be termed as negligent if the treatment of a patient
requires the assistance or opinion of other health professionals from the same field. Thus, the
assignment intended to discuss potential harm of medical negligence and impact of same on
patients along with NMBA Standard and ACSQHC standards in the following paragraphs.
Description of the incident:
The medical malpractice is a common incident in the clinical setting which not affect the nursing
practice but also impacts the quality of life of the patient (aihw.gov.au 2018). Hence, this paper
will focus on one such medical malpractice, medical negligence. The term medical negligence is
referred to the incidents where healthcare professionals failed to provide the care up to the
standard of care despite the possession of skills of an expert which further resulted in in
breaching of duty of care (Small et al., 2016). In this case study, Mavis Lopez, the accused
individual was subjected to charges of manslaughter on the ground of the medical negligence of
her patient. (Bibby, 2019). The case study provided an insight into the fact that the nurse already
reported that the patient had an extensive medical history such as high blood pressure and severe
heart disease and had difficulty in swallowing. For administrating medication, Lopez crushed

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three medications, mixed with saline and injected it in 100ml intravenous drip of the patient. The
medicines were administrated without any second opinion of any senior nurse or the presence of
a senior nurse.
Consequence:
The immediate consequence of medical negligence was immediate death of the patient.
According to NMBA code of conduct nursing practice principle four: the core values of the
nurses provide safe, honest and compassionate care to the patients without causing possible harm
to the patient (Nursingmidwiferyboard.gov.au., 2019). While Lopez exhibited empathy towards
the patient and for minimizing the suffering of the patient, she administrated intravenous
medication, she experienced ethical conflicts in between beneficence and non-maleficence.
According to NMBA standard 6, it is the responsibility of a nurse to provide safe and responsible
care by addressing medical errors (Nursingmidwiferyboard.gov.au. 2019). The accused
individual experienced ethical conflicts and failed to balance between possible risk and benefits.
On the other hand, this incident highlighted the gap in delivery of the care. Vrbnjak et al.
(2016), highlighted that the medication errors in the clinical field are solely due to the medical
negligence in absence proper guiding protocol. Hence, it is the legal obligation of nurses to
provide safe and responsive care to the patients by addressing the medication error. While
she was not found guilty as patient was already in critical condition, the negligence cannot be
ignored.
Nursing action and description:
According to NMBA standard 7, nurses are required to monitor the progress of the
patient for detecting adverse changes in the patient and preventing sudden death in the clinical

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setting (Nursingmidwiferyboard.gov.au., 2019).. Taking a deep insight into the situation, the
accused individual did not follow 7 rights of medication administration while administrating
medication (Harvey et al., 2019). Nurses are trained to practice “ 7 rights of medication
administration” such as right patient, right drug, right dose, right time, right reason and right
documentation. The delivery of care to patients should be exercise by health professionals in
accordance with the appropriate guiding protocol (Wilson et al., 2016). The case highlighted
that no documentation and the right route of administration observed which resulted in
difficulties for the patient as the patient had a history of high blood pressure and cardiovascular
disease.
While the professionals relied on the medication as a primary intervention, the wrong
medication or wrong route of medication can expose patients to a potential harm (Hewitt, Tower
& Latimer, 2015). In this case, the nursing curriculum should be incorporated with different
aspect of safety and quality of care.
Considering the case study, in order to improve their practice in a way that prevents the
reoccurrence of the incident, nurses are required to involve themselves in the training process
regarding documentation and medication administration and seek advice from the supervisors
(Manias et al., 2015`). The nurses are required to involve themselves in the reflective practice
and the workshops.
Rolf’s model:
What:
Considering Rolf model of reflection, medical negligence and breaching of duty of care
are a prominent scenario in the case. However, as a registered nurse, I believe that it is the
responsibility of the nurse to conduct appropriate administration of medication. The lack of

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communication was missing in this case which further led to the wrong route of medication
administration.
So what:
From the case study, I have gathered an in-depth understanding that it is crucial to
balance between beneficence and non-maleficence. Moreover, it is important to develop critical
skills according to the 7 rights of administration and exhibit awareness of the medication
administration.
Now what:
In order to avoid reoccurrence of the issue, I will communicate with my supervisor
regarding medication administration and document the administration. I will further assess the
vital status of the patient for evaluating the impact of medication.
Conclusion:
In summary, it can be said that the scenario represents the clear gap in practice. The
proper duty of care and patient advocacy from the end of professionals was missing in this case.
The breaching duty of care through wrong administration of medication is one of the most
common practices exercised by the health professional. In this context, there is an increasing
gap in the health care setting which can is required to address with proper nursing
practice, proper training for better health outcome. Proper communication is required to do
with the supervisors in order to address the gap in nursing practice.

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References:
Aihw.gov.au (2018) Injury Overview - Australian Institute of Health and Welfare. Retrieved 5
August 2019, from https://www.aihw.gov.au/reports-data/health-conditions-disability-
deaths/injury/overview
Bibby, P. (2019). Sydney grandmother who died after nurse's error was already 'at death's
door', court hears. [online] The Sydney Morning Herald. Available at:
https://www.smh.com.au/national/sydney-grandmother-who-died-after-nurses-error-was-
already-at-deaths-door-court-hears-20150222-13lim1.html [Accessed 16 Aug. 2019].
Fletcher, J., Hamilton, B., Kinner, S. A., & Brophy, L. (2019). Safewards Impact in Inpatient
Mental Health Units in Victoria, Australia: Staff Perspectives. Frontiers in
psychiatry, 10.
Harvey, C., Hegney, D., Sobolewska, A., Chamberlain, D., Wood, E., Wirihana, L., ... & Wake,
T. (2019). Developing a community-based nursing and midwifery career pathway–A
narrative systematic review. PloS one, 14(3), e0211160.
Hewitt, J., Tower, M., & Latimer, S. (2015). An education intervention to improve nursing
students' understanding of medication safety. Nurse education in practice, 15(1), 17-21.
Ingham-Broomfield, R. (2017). A nurses' guide to ethical considerations and the process for
ethical approval of nursing research. Australian Journal of Advanced Nursing,
The, 35(1), 40.

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Manias, E., Gerdtz, M., Williams, A., & Dooley, M. (2015). Complexities of medicines safety:
communicating about managing medicines at transition points of care across emergency
departments and medical wards. Journal of clinical nursing, 24(1-2), 69-80.
Nursingmidwiferyboard.gov.au. (2019). Available at:
https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-
standards.aspx [Accessed 28 Jul. 2019].
Small, K., Sidebotham, M., Fenwick, J., & Gamble, J. (2016). Midwifery prescribing in
Australia. Australian prescriber, 39(6), 215.
Vrbnjak, D., Denieffe, S., O’Gorman, C., & Pajnkihar, M. (2016). Barriers to reporting
medication errors and near misses among nurses: A systematic review. International
journal of nursing studies, 63, 162-178.
Watson, R. (2015). Ethics and open access. Nursing open, 2(2), 47.
Wilson, A. J., Palmer, L., Levett-Jones, T., Gilligan, C., & Outram, S. (2016). Interprofessional
collaborative practice for medication safety: Nursing, pharmacy, and medical graduates’
experiences and perspectives. Journal of interprofessional care, 30(5), 649-654.