“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) emphasises the administration of medication is an area of concern for public safety, and generally follow the principles laid down by law. The NMC also publish the appropriate guidelines for nurses on the administration of medicines (NMC 2004).
The Standards for Medicine Management (NMC 2010) states that I am “accountable for your actions and omissions”. This incident has highlighted the need for vigilance at all times. Rule 7 of the Midwives Rules and Standards (NMC2004), states that “A practising midwife shall only supply and administer those medicines, including analgesics, in respect of which she has received appropriate training as to us, dosage and method of administration”. Although the local policy and procedures were followed, it seems that unintentionally the incorrect drug was administered.
As a registered midwife I am up to date with all training, I have never before in my practice made a drug error. Research studies demonstrate 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 incident discussed demonstrates how easily practitioners can become distracted when checking and administrating drugs.
With regard to reporting drug errors, (Webster and Anderson 2002) found that several areas of concern emerged, including nurses’ confusion regarding the definition of drug errors and the appropriate actions to take when they occurred. Nurses also reported their fear of disciplinary action and the loss of their clinical confidence. The Guidelines for the Administration of Medicine by the Nursing and Midwifery Council advises that an open culture exists in order to encourage the immediate reporting of errors or incidents in the administration of medicines.
It also advises that nurses who have been made the subject of local disciplinary action, has discouraged the reporting of incidents which is detrimental to patients. Furthermore, all errors and incidents have a thorough investigation at local level, taking into account the full context of the circumstances, which requires sensitivity (NMC 2004). 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.
As discussed previously, the administration of medicines is a vital part of the midwives role. Drug error is costly in terms of increased hospital stay, resources consumed and patient harm (Webster and Anderson 2002). A study by Kapborg (1999) showed that the most common errors among nurses were administration of the wrong drug and levels of drugs administered exceeding the prescribed ones.
From my experiences of the incident, I have learnt a valuable lesson. I no longer allow myself to be distracted from other members of staff, patients or relatives when I am in the process of administering medication. During this time I only have discussions with the patient to whom which I am given them their medication.
I realise the seriousness of my error and I have since read literature to educate myself, the important of not repeating the same mistake 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 feel that I have improved my practice and became a better midwife, thus improving patient care.
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