“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.
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.
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 I had allowed myself to become complacent about drug administration. The Code States that midwives shall, “provide a high standard 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 potential effects to the patient concerned. The Standards for Medicine Management, (NMC 2010), states “ as a registrant, if you make an error you must take any action to prevent any potential harm to the patient”. The patient had suffered no real harm as a result of the dug error and she was recovering well post-operatively.
The main advantage regarding this incident is that the patient concerned came to no serious harm. Personally, I feel that I have learnt from the experience, thus enhancing my clinical practice. Gladstone (1995) agrees that planning problem solving strategies and accepting responsibility is found to lead to positive changes. This incident has highlighted the need for vigilance at all times. I have changed my practice to avoid drug errors occurring in the future, I am aware not to be complacent with drug administration. I will never let this or any other incident occur due to lack of concentration again in my practice.
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). Consequently, detailed and comprehensive procedures and standards exist, thus ensuring safe, legal and effective practice, for example of the Medicines Act (1968) and NMC’s Guidelines for the Administration of Medicines (2007). The Consumer Protection Act 1987 and Medicines Act 1968 require that to administer medication, the practitioner has 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. Nursing & Midwifery Council’s Code of Professional Conduct (2004)...
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