Medication Error in Nursing Practice: A Gibbs’ Reflective Cycle Case Study

 Healthcare is an ethical-based profession that is based on patient safety, responsibility, and accountability. Even a small error might lead to grievous damages or even death. The problem of medication errors is one of the most paramount tasks of the nursing practice that should be emphasized with respect to the significance of reflective learning. This medication error reflection essay applies reflection on medication error using Gibbs cycle to a real-life case involving Ruth Stoll, exploring the causes, consequences, and lessons for nursing practice. By using medication error reflection examples, nurses can strengthen clinical judgement and prevent similar incidents in the future.

Description

This nurse medication error reflection example focuses on a fatal medication-related incident involving a 71-year-old patient, Ruth Stoll. She presented herself in Clinpath Laboratories to undergo routine pre-surgery blood as per the scheduled cardiac surgery. Meanwhile, the same room was occupied by another patient Martha Kovendy. The nurse who was present at the time of blood collection incorrectly labeled the blood samples meaning that the samples of the patients were switched.

After a few days, when Ruth Stoll needed a blood transfusion, she was given incompatible blood, because of the error made during the previous mislabelling. This omission caused serious complications and Ms Stoll died six days later and regrettably, it was a fatal mistake. The case shows that one mistake in identifying the patient may turn into a life-threatening situation.

Feelings

I was in a state of great shock, sadness, and disbelief upon hearing this event. It was unfortunate as a nursing professional to understand that such a preventable error led to the death of a patient. I also sympathized with the family of the patient as they had experienced the worst loss after professional negligence. This emotional reaction makes it clear that medication safety is really serious and this is the moral responsibility of nurses.

Evaluation

An analysis of the incident supports the fact that there were critical failures in safety practices. There was negligence in patient identification procedures and secondary confirmation of blood samples by the seniors was not done. Lack of checks and balances was also an ingredient to the error. On the positive side, the case triggered investigations and identified system-level flaws that had to be mitigated in the nearest future.

Analysis

Analytically, the incident leading to negligence and low adherence to standard operating procedures was the root cause. The nurse did not ensure patient identity based on the approved ways, i.e., verification of a wristband, or oral confirmation. There was also lack of proper supervision and breakdown of communication which aggravated the situation.

The example of professional accountability and adherence to national safety standards is supported by this medication error reflection. Ethical theory of beneficence and non-maleficence was also not followed, as the responsibility to safeguard the patient against harm was not fulfilled. Studies have indicated that close compliance with identification procedures and inclusion of patients or family members in the process of care provision go a long way in minimizing such errors.

Conclusion

This Gibbs cycle-based reflection on medication error demonstrates how disastrous the impacts of improper medication safety practice can be. Human factors that lead to medication errors are usually workload pressure, complacency, and lack of vigilance. The example of Ruth Stoll shows that the inability to adhere to fundamental nursing duties may cause irreparable damage. Reflective practice enables nurses to be aware of these dangers and enhance future performance.

Action Plan

Based on this medication error reflection essay, my action plan focuses on strengthening patient safety and professional competence. To begin with, I will make sure that I strictly adhere to the procedures regarding patient identification and documentation in all procedures related to medication. Secondly, I will also proactively consult with senior colleagues and attend safety training programmes.

I will also engage in reflective learning on a regular basis by looking back at experiences in clinical practice with the view of identifying areas in which I can improve. The improvement of communication with patients and families will also be prioritized to minimize the errors and misunderstandings. Ongoing learning and following the evidence-based guidelines will facilitate safer nursing practice.

Final Conclusion

The reflection on medication error with the help of the Gibbs cycle allows nurses to be more critical about the incidents, improve patient care, and facilitate professional growth. If you are struggling to structure a nurse medication error reflection example or require help with a medication error reflection essay, expert assignment help, online assignment help, and guidance from an experienced assignment helper UK can make a significant difference.

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