Nursing and Reflective Practice
“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 ward. I have chosen Gibbs model of reflection (1988) to guide my reflective process. (Gibbs 1998) (Appendix I). Gibbs model (1998) goes through six important points to aid the reflective process, including description of incident, feelings, evaluation, analysis, conclusion and finally action plan. The advantage of Gibbs’s six-stage model is that it allows you to learn from experiences and make changes for your future practice.
Description
The incident involves the administration of a wrong opiate drug to a postnatal patient. The incident occurred whilst checking and administering a controlled drug. The drug error was discovered by the co-ordinator at the end of the day shift. During the daily checking of the controlled drugs, the co-ordinator and another midwife, found a discrepancy with the number of Diamorphine 10mg and Morphine 10mg ampoules, there being one too many Morphine 10mg ampoules and one too few of the Diamorphine 10mg ampoules. Myself, as the midwife checking the drug, along with the midwife who administered the Diamorphine to her patient, were the only midwives to have administered a controlled drug on the shift. The drugs were correct on the previous daily check.
Feelings
On being informed of the error my initial feelings were of disbelief and horror. I was confused; two midwives had checked the drug and neither of us noted the mistake. I felt very upset and embarrassed that I had made this mistake, since qualifying as a midwife I have never made such an error. When the error was highlighted I instantly remembered checking Diamorphine and mixing the drug with 2mls of water for injections, I remembered talking to the other midwife concerned about personal affairs. I felt ashamed that I had allowed myself be distracted during such an important task. I was very angry that
This is a reflection on an incident that occurred during a shift on the labour ward. I have chosen Gibbs model of reflection (1988) to guide my reflective process. (Gibbs 1998) (Appendix I). Gibbs model (1998) goes through six important points to aid the reflective process, including description of incident, feelings, evaluation, analysis, conclusion and finally action plan. The advantage of Gibbs’s six-stage model is that it allows you to learn from experiences and make changes for your future practice.
Description
The incident involves the administration of a wrong opiate drug to a postnatal patient. The incident occurred whilst checking and administering a controlled drug. The drug error was discovered by the co-ordinator at the end of the day shift. During the daily checking of the controlled drugs, the co-ordinator and another midwife, found a discrepancy with the number of Diamorphine 10mg and Morphine 10mg ampoules, there being one too many Morphine 10mg ampoules and one too few of the Diamorphine 10mg ampoules. Myself, as the midwife checking the drug, along with the midwife who administered the Diamorphine to her patient, were the only midwives to have administered a controlled drug on the shift. The drugs were correct on the previous daily check.
Feelings
On being informed of the error my initial feelings were of disbelief and horror. I was confused; two midwives had checked the drug and neither of us noted the mistake. I felt very upset and embarrassed that I had made this mistake, since qualifying as a midwife I have never made such an error. When the error was highlighted I instantly remembered checking Diamorphine and mixing the drug with 2mls of water for injections, I remembered talking to the other midwife concerned about personal affairs. I felt ashamed that I had allowed myself be distracted during such an important task. I was very angry that
References: Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit, Oxford: Oxford Polytechnic. Gladstone, J. (1995). Drug administration errors: a study into factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing. Vol. 22. pp. 628-37. Gladstone, J. (1996). Discipline fears mean drug errors are going unreported. Nursing Standard. Vol.10(2) pp. 4-10.