Medication Errors: The Fine Lines between Palliation and Tribulation
The incident took place on my clinical placement in a busy ward in a government hospital. A 3rd year student nurse was assisting his mentor with the morning drugs and doctors round was also being carried out by the side. As it was morning, the ward was busy with porters taking patients to theatre and doctors coming to and fro to begin the ward round.
During the doctors’ round he was about to give a patient the incorrect dosage of a drug but was interrupted by one of the porters asking him where the patient is. Fortunately, he realized his mistake quickly when he checked against the drug kardex, the correct dosage and realized that he had to remove 1 tablet to make it the correct dosage. Thus, the patient received the correct dosage of the drug.
Drug administration is one of the highest risk areas of nursing practice and a matter of considerable concern for both managers and practitioners (Gladstone 1995). Research studies carried out by the Royal College of Nursing (2006) found that nurses administered the wrong drugs because they were interrupted during their calculations. Additionally, Gladstone (1996) found that many errors occurred because of distractions in the ward, illegible writing or because nurses failed to check the patient’s name-band.
When administration of medicines takes place in an institution, such as a hospital ward or nursing home, it is important that detailed and comprehensive procedures and standards exist to encourage safe, legal and effective practice, in terms of the Medicines Act (1968) and NMC’s Guidelines for the Administration of Medicines (2004) (Shepherd 2002). The Consumer Protection Act 1987 and Medicines Act 1968 requires the practitioner to ensure that the right medication is given to the right patient, at the right time, in the right form of the drug, at the right dose and right route (Griffith 2003).
At the time I was in shock that a 3rd year student was given that huge responsibility. I was amazed at how easy it would have been to make an error when your head is occupied with something else, such as the increased workload in the ward. I chose this incident to reflect upon as it made me quickly realize how potential errors can be made in a matter of seconds. It occurred to me that he might have given the wrong medication before as well and he may not have realized. Clinical experiences can be stressful for nursing students (Sprengel 2004).
I also reflected on the fact that he was a Student Nurse and that his accountability is upheld by his mentor. I then thought that if something bad had happened then his mentor would get the blame and she would be held accountable for it. Throughout the morning, his mentor explained that mistakes happen all the time in a ward and it is easy to make mistakes with the administration of medicines as there are always distractions, like patients asking questions, phone calls, other nurses asking you questions about patients. This made me wonder actually how many mistakes happen without any thoughts or feelings of what could have happened. Although, she did assure him that, she would not have let him get as far as taking the medication to the patient without her checking it as she was supervising him.
I feel that reflecting on and learning from experiences, including your errors, can help you to avoid frequent mistakes and at the same time, identify fruitful aspects of that scenario. To enable students to develop their proficiency in clinical skills, nurse educators must find innovative methods of supplementing the practice placement experience.
The positive aspect behind this reflection was that he corrected his mistake on time. Furthermore, Gladstone (1995) adds that procedures for reporting and dealing with drug errors also need improvising. The negative aspect of my reflection was that the mentor just encouraged him and she should have given him some minimal form of punishment as well so that he never forgot his mistake.
Nursing & Midwifery Council’s Code of Professional Conduct (2004) emphasizes that the administration of medications is an area of concern for public safety, and generally follows the principles laid down by law. The NMC also published the appropriate guidelines for nurses on the administration of medicines (NMC 2004). My analysis according to the situation was that the incident happened due to lack of staff in the ward as morning duty is very busy in every hospital, distractions should be kept to a minimum so that nurses are able to concentrate while preparing and administering medications, as this will contribute in preventing potential errors.
In conclusion to this we nurses should realize the seriousness of medicational errors. By implementing the five rights of drug administration, as previously described by Griffith (2003), this will always ensure best practice and enhance my nursing care. I personally feel that the staff nurses should not completely depend upon students. If they give them responsibility they should always have an eye on them that they are doing their work in a correct way.
To learn from our mistakes, Williams (1996) believes we first need to acknowledge that we have made them. As mistakes in a professional capacity do happen, these mistakes need to be used as a learning experience to reflect upon and to therefore avoid them from happening again. Gladstone (1995) deems that the potential for error in drug administration on the hospital ward makes this a concern for all of nursing staff
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