Addressing Medication Errors Through Reflective Nursing Practice

1. REDUCED RISK AND PATIENT SAFETY

2. Introduction: Today, I will discuss a presentation on medication errors and how reflective nursing practice can use Gibbs' Reflective Cycle to address problems that lower risk and improve patient safety.

3. Reflective Practice used in Nursing • The process by which people analyze their experiences in order to obtain new perspectives on their entire profession is called reflection. Individuals can enhance their employment or the standard of care they provide to others by reflecting on their practices (Ingham-Broomfield, 2020).

4. INTRODUCTION OF GIBBS’S REFLECTIVE CYCLE • Gibbs' reflection model states that the reflecting events are grounded in clinical practice. • Graham Gibbs created it in 1988 to provide some structure to learning through experiences. • It is especially well-suited to recurring encounters due to its cyclical structure, which also provides a framework for experience interpretation. • This framework helps you create goals for the future and allows you to draw lessons from both good and bad experiences. There are six steps in all.

5. Description • At the time, I was a licensed practical nurse in India. The nurse on the morning shift gave me over. She quickly handed me off in order to go to her important duties, and she did not adequately document anything. • I discovered that one medication was pending once I began taking them. I called her several times, but she didn't answer. • I spoke briefly with the supervisor. The patient looked unsure when we both went to perform a cross-check. Before giving her, the insulin shot, I checked her blood sugar, which was within normal ranges. She shook and started to perspire after a little while. We immediately notified the doctor. Her blood sugar was low when I took a reading. • I started a dextrose infusion following the doctor's written directions. After an hour, her condition was steady. I informed the patient of his mistake and offered him psychological support to help him calm throughout the event.

6. Feelings I was worried as I monitored the patient's progress during the incident because the patient had suffered because of an error on my part, but it turned out that I resolved the matter calmly and gave the patient psychological support. Because of the inadequate documentation, I was especially disappointed with the morning staff members.

7. Evaluation • The patient suffered as a result of my error, which was an unpleasant aspect of the situation. But because I approached the situation effectively the problem was resolved in an hour and the patient was safe, so everything worked out well. I took away from the experience to carefully examine all paperwork before approving to personnel move.

8. Analysis • Reviews of a progress note, client reports, and medication records are required to accomplish this. • In line with the Communicating for Safety Standard of the National Safety and Quality Health Service Standards, "The Communicating for Safety Standard strives to promote prompt, focused, and efficient communication and documentation that support ongoing, coordinated, and safe patient care."

9. Action Plan • I believe I would proceed more cautiously with the handover. • In addition, I will communicate with the doctor directly if there is a lack of paperwork. • Every issue has to be approached in the future with the utmost confidence. In emergency situations, communication is essential, as is being ready for them at all times. • I'm going to see a doctor to reduce the likelihood of this happening. Punishment may actually reduce reporting errors because it results in discipline and shame for repeat offenders. However, ignoring the problem makes more negative events likely to happen, which puts more individuals in danger. • Supervisors and review boards are encouraged to replace the blame-shame-discipline framework with a preventive and informative framework rather than placing blame (Rodziewicz et al., 2023).

10. Action Plan 2 • The use of vests for medicine administration (prescription, preparation, and distribution in emergency rooms is one way to increase patient safety by reducing disruptions and, consequently, drug errors. • A promotion campaign is necessary to encourage professionals to use vests, even if medical experts think they are beneficial for minimizing disruptions and lowering prescription errors. Protocol compliance is minimal (Castro-Rodríguez et al., 2023).

11. Conclusion I believe I would be more cautious while accepting and transferring the handover. Furthermore, I will talk with the doctor directly if there is a lack of paperwork. I shall also speak with the patient's relatives before giving myself an insulin injection.

12. Thank You