“Reflection is not just a thoughtful practice, but a learning experience” (Jarvis 1992)
This is a reflection on an incident that occurred during a shift on the labour keep. I have chosen Gibbs model of reflection (1988) to guide my reflective process. (Gibbs 1998) (Appendix I). Gibbs model (1998) goes through half a dozen important factors to aid the reflective process, including information of incident, feelings, evaluation, examination, conclusion and finally action plan. A benefit of Gibbs’s six-stage model is that it allows you to learn coming from experiences and make alterations for your long term practice.
Description
The incident entails the supervision of a wrong opiate drug to a postnatal patient. The incident happened whilst checking out and applying a controlled medication. The drug error was discovered by the co-ordinator at the end of the day change. During the daily checking of the controlled prescription drugs, the co-ordinator and one other midwife, discovered a discrepancy together with the number of Diamorphine 10mg and Morphine 10mg ampoules, there being one a lot of Morphine 10mg ampoules and one too little of the Diamorphine 10mg suspension.
Me, as the midwife checking the medication, along with the midwife who used the Diamorphine to her affected person, were the sole midwives to have administered a controlled drug on the shift. The drugs had been correct on the previous daily check.
Thoughts
On being informed of the mistake my initial thoughts were of disbelief and fear. I was baffled; two midwives had checked the medicine and neither of us noted the mistake. I felt very upset and uncomfortable that I experienced made this blunder, since being qualified as a midwife I have not made this sort of an error. When the error was highlighted I immediately remembered examining Diamorphine and mixing the drug with 2mls of water for shots, I remembered speaking to the additional midwife concerned with personal affairs.
I felt uncomfortable that I got allowed personally be distracted during such an important task. I was very angry that I acquired allowed myself to become satisfied about medication administration. The Code Says that midwives shall, “provide a high common of practice and care at all times”, (NMC 2008), I felt that I had not only failed the patient but the profession too. I started to worry about the effects to the patient worried. The Standards pertaining to Medicine Management, (NMC 2010), states ” as a registrant, if you make an error you must take any actions to prevent any kind of potential harm to the patient”. The patient experienced suffered no real harm as a result of the dug error and she was recovering well post-operatively.
Analysis
The main benefits regarding this kind of incident is that the patient worried came to no serious harm. In person, I feel that I have discovered from the knowledge, thus enhancing my clinical practice. Gladstone (1995) confirms that preparing problem solving tactics and taking responsibility is found to lead to positive changes. This kind of incident offers highlighted the advantages of vigilance at all times. I have changed my practice to avoid medication errors happening in the upcoming, I am mindful not to be complacent with medicine administration. I will never let this or any other occurrence occur because of to lack of concentration again in my practice.
Analysis
Medication administration is one of the greatest risk areas of nursing practice and a matter of considerable matter for the two managers and practitioners (Gladstone 1995). Subsequently, detailed and comprehensive types of procedures and criteria exist, as a result ensuring safe, legal and effective practice, for example of the Medicines Act (1968) and NMC’s Suggestions for the Administration of Medicines (2007).
The customer Protection Act 1987 and Medicines Act 1968 require that to administer medication , the practitioner has to ensure the fact that right medicine is given, to the right individual, at the most fortunate time, in the proper form of the drug, at the right dose and right route. Medical & Midwifery Council’s Code of Professional Conduct (2004) emphasises the administration of medication is an area of concern for general public safety, and usually follow the principles laid down by law. The NMC likewise publish the appropriate guidelines pertaining to nurses on the administration of medicines (NMC 2004).
The Standards for Medicine Managing (NMC 2010) states that I am “accountable for your activities and omissions”. This event has featured the need for vigilance at all occasions. Rule 7 of the Midwives Guidelines and Criteria (NMC2004), says that “A practising midwife shall only supply and administer those drugs, including analgesics, in respect of which she has received appropriate schooling as to us, serving and technique of administration”. Although the local policy and methods were followed, it seems that unintentionally the incorrect drug was administered.
As a registered midwife I am up to date using training, I have never ahead of in my practice made a drug mistake. Research studies display that many drug errors within clinical practice occur as a result of distractions on the ward, illegible writing or because nurses failed to check the patient’s name-band (Gladstone 1996). The event discussed displays how easily practitioners may become distracted once checking and administrating drugs.
With regard to reporting drug problems, (Webster and Anderson 2002) found that several areas of concern appeared, including nurses’ confusion about the definition of drug errors and the appropriate actions to take if they occurred. Healthcare professionals also reported their fear of disciplinary actions and the damage of their clinical confidence. The rules for the Administration of Medicine by the Nursing and Midwifery Council recommends that an open culture exists in order to encourage the immediate reporting of errors or incidents in the operations of medicines.
It also advises that nurses who have been made this issue of local disciplinary action, provides discouraged the reporting of incidents which is detrimental to patients. Furthermore, all problems and situations have a thorough investigation at local level, taking into account the full framework of the instances, which requires sensitivity (NMC 2004). To learn from our errors, Williams (1996) believes we first need to acknowledge that we have made all of them. As mistakes in a professional capacity do happen, these mistakes need to be used as a learning knowledge to reflect after and to therefore avoid them via happening again.
Conclusion
As discussed previously, the administration of medicines is a vital part of the midwives role. Medicine error is costly in terms of increased hospital stay, resources consumed and sufferer harm (Webster and Anderson 2002). A study by Kapborg (1999) showed that one of the most common errors among rns were government of the incorrect drug and levels of drugs administered exceeding beyond the approved ones.
Action Plan
From my experiences of the incident, I have learnt a valuable lessons. I no for a longer time allow me to be distracted from all other members of staff, patients or relatives when I am in the method of administering medication. During this time I only have conversations with the affected person to whom which usually I am provided them all their medication.
I realise the seriousness of my error and I have seeing that read literature to educate myself, the important of not repeating a similar mistake once again. My reflective practice has encompassed critical analysis of my self-awareness. Through this process, I have been able to learn from my mistake. The drug error incident has been a learning curve and I now experience that I have improved my practice and became a better midwife, hence improving patient care.
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