Reflective Journal: Experiences in Patient Safety and Nursing Practice

This reflective journal, written by a registered nurse, explores two critical incidents encountered in clinical practice, emphasizing the importance of patient safety and adherence to the National Safety and Quality Health Service (NSQHS) Standards. The first incident describes a near medication error, highlighting the significance of medication safety and the role of NSQHS Standard 1. The second incident involves a nurse's failure to document vital signs, leading to delayed treatment and underscoring the importance of comprehensive care and NSQHS Standard 2. Through Gibbs' reflective cycle, the author analyzes the situations, detailing feelings, evaluations, and action plans. The journal references relevant research to support the analysis, including studies on medication errors, the impact of insufficient training, and the importance of comprehensive care plans. The author concludes with a commitment to apply the lessons learned to improve nursing practice and ensure patient safety in future clinical settings.

Title
Name
Student’s id
Date

Introduction
Keeping patients safe in healthcare settings is a fundamental goal to achieve a high-
quality care. All the healthcare providers are committed to ensure quality and patients’ safety
while providing care. Quality of care is a key component which is a route to dignity as well
as equity. In order to achieve universal health coverage it is essential to deliver health
services that meet the criteria of quality (Sollid et al., 2019). Being a registered nurse (RN), I
have also experienced some situations in my clinical settings where patients’ safety and
quality of care played a significant role. The learning of the experience is related to NSQHS
standards. Here, I am going to reflect my two different experiences using the Gibbs’
reflective cycle.
Standard 1: Medication Safety
Description
In my clinical settings, once I had responsibility to take care of a post-operative
patient who was at a risk of getting infected easily. Therefore, providing medicine was crucial
for that patient as wrong medication usage might create the risk of having infection.
Therefore, I had to be more cautious, but initially I was not careful and I was also going to
give an inappropriate medicine to the patient, however, my senior assistant stopped me and it
reminded me of the NSQHS standards I learned in my theoretical practice.
Feelings
I feel, delivering health care that minimizes the risk and harm includes reducing
medication error and a hygienic practice. NSQHS standards are extremely supportive for the
freshly recruited nurses to work appropriately. I was also going to take a wrong step but I

would have followed NSQHS standard strictly then the risk of taking any wrong decision
could have lessened.
Evaluation
On evaluation, I can say that this experience was quite helpful for me as it helped me
to practically utilize my knowledge of NSQHS standards I learned in theory. There are
various researches regarding the safety of patients which is the greatest concern for all the
healthcare organizations and the study of Institute of Medicine (IOM) reported that almost
98000 people die annually due to medication errors (Johnson, 2016).
Analysis
According to fourth NSQHS standard describes medication safety as an essential part
of nursing practice. This standard describes the system and strategy that ensures the clinician
is prescribing a medicine safely, and it is also being properly administered and monitored by
the nurses. Several studies indicated the role of medication review to prevent any adverse
drug effects and it is considered as the priority of evaluation (Nguyen et al., 2017). Also, a
study on the perception of nurses produced the fact that insufficient training and knowledge
about the essential nursing standards can cause medication error. In this case also, initially I
forgot my theoretical knowledge and did not verify the medication safety (Ludin, Ariffin &
Ilias, 2019).
Conclusion
This incident was like an eye-opening to me and it made me realized about the
importance of medication safety.
Action plan

The experience I gained from this learning will be highly helpful in future as well. I
will always follow the NSQHS standards in order to maintain the safety and quality of care.
Standard 2: Comprehensive care
Description
While working as a registered nurse, I witnessed another incident, where the nurse
forgot to document vital signs of patients and as a result, the treatment got delayed. One of
the important duties of nurse is to keep records of the medical information of the patients for
treatment as well as future reference. But, as the nurse did not documented information,
doctors could not initialize the treatment procedure which affected the health status of the
patient.
Feelings
As a fresher nurse I have never realized that documentation can be this much
important in the treatment of a patient. But, this incident changed my view and I also feel that
if treatment gets delayed then that can be life threatening as well. However, I also get nervous
to think that what the scenario could be if the treatment got more delayed.
Evaluation
On evaluation it can be said that documentation is an important part of comprehensive
care plan which is the fourth standard of NSQHS. According to studies, comprehensive care
plan should be developed before the treat procedure and it is extremely essential to provide
proper treatment (Stevenson, Israelsson, Nilsson, Petersson & Bath, 2016). However, this
incident helped me to gain more knowledge about the different perspectives of healthcare.
Analysis

On analysis of the whole incident, a lot of new information can be found. According
to the NSQHS standard, developing comprehensive care plan such as assessing, documenting
the essential information can minimize the risk of harm in many identified areas. Vital signs
include crucial information, alert, risk and others which are highly necessary to be
documented and the nurses should keep the records of vital signs of the patients in this regard
(Deisseroth, Zhang, Gradinaru & Schneider, 2016). Studies indicated that nurses should
follow NHSQS standards while providing care and keep record of the vital signs of the
patients (Mansour, Al Shadafan, Abu-Sneineh & AlAmer, 2018).
Conclusion
Being a registered nurse I faced various incidents and this incident also clearly
indicated the importance of developing comprehensive care plan. If the nurse would not have
forgot to document the important information then the whole scenario could be different. It
also helped me in enriching my knowledge regarding the development of care plan.
Action plan
The knowledge I gained from this learning is quite helpful and in future, I will also
utilize this experience and never forget to keep the records of vital signs of the patients. It
will help the treatment procedure and at the same time, I will also be successful in following
important NSQHS standards.
Conclusion
Here, in this paper I have shared two different experiences of mine which I gained
while practicing as a registered nurse. However, both the incidents indicated poor nursing
performance of me and my fellow colleague but at the same time it helped in utilizing
theoretical knowledge into the practical settings. I have also discussed my view along with

some literature evidences in this context. All the studies indicated the importance of
medication safety and development of comprehensive care plan, documenting the important
information of patients. Finally, I can say that the knowledge I gained from these experience
will surely make me more responsible nurse in future.

References
Australian Commission on Safety and Quality in Healthcare (n.d.). The NSQHS Standards
Retrieved from https://www.safetyandquality.gov.au/standards/nsqhs-standards
Deisseroth, K., Zhang, F., Gradinaru, V., & Schneider, M. B. (2016). U.S. Patent No.
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https://patentimages.storage.googleapis.com/f3/38/74/8fa9d7517eeb76/
US9274099.pdf
Johnson, K. F. (2016). US Nursing Students' Perceptions of Safe Medication Administration.
Retrieved from http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?
article=4331&context=dissertations
Ludin, S. M., Ariffin, S. M., & Ilias, N. A. (2019). Nurse Perception on Medication Error in
Intensive Care Unit. Journal of Medical Biomedical and Applied Sciences, 7(7), 267-
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Mansour, M. J., Al Shadafan, S. F., Abu-Sneineh, F. T., & AlAmer, M. M. (2018).
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impact of a multivariate model-based strategy to target high-risk patients. PloS

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Stevenson, J. E., Israelsson, J., Nilsson, G. C., Petersson, G. I., & Bath, P. A. (2016).
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