Quality nursing practice that employs evidence-based approach and reflective practice

enhances patient safety and improves quality of care. Nurses work daily in a complex and

demanding environment; it is essential that all their decisions are informed by appraising and

evaluating available evidences. In addition, nurses need to critically reflect on past

experiences and knowledge while making clinical judgements by asking themselves

questions that may help ensure patient safety. This essay will discuss an incident that

occurred in a hospital wherein a medication error made by a nurse led to the death of a

Sydney grandmother. The incident will be analysed to identify issues related to the

medication error. Also, the consequences of the error and measures to prevent reoccurrence

will be highlighted with the use of the National Safety and Quality Health Service Standard.

The Rolfe et al’s (2001) reflective method will be utilized in critically reflecting on the

nurse’s action and inaction.

In this case study, a nurse administered oral medications intravenously to a Sydney

grandmother (Bibby,2015). The 97 years old patient, Nymphea Anderson arrived hospital

presenting symptoms that include nausea, urinary tract infection, angina and dehydration. The

patient had suffered an episode of heart attack and her health greatly declined but her

prognosis improved prior to the nurse starting her shift. However, because of the patient’s

swallowing difficulty, the nurse decided, against proper practice and without consulting other

registered nurses to crush up three different oral tablets and administered them through the

patient’s intravenous drip. The patient’s subsequent death minutes later was attributed to the

wrong route through which the nurse administered the medication. This is a breach of the

(ACSQHS, 2017) medication safety standard 4 that provide guidelines for improved quality

and safety around medication administration. The nurse also breached standard 1 of Nursing

and Midwifery Board of Australia [NMBA], (2018) when she failed to critically reflect on

her action and the potential consequence on the patient safety.

 There are several consequences following the nursing incidence. The nurse must have

suffered emotional and psychological distress. According to Agyemang and While (2010),

nurses who made medication errors especially ones ending in fatality suffer feelings of

guilt, fear and persistent loss of confidence. They also found there are damages to both

professional and personal lives of the erring nurses as they are embarrassed, ashamed

and the occasional blame from managers and colleagues. In addition, there is financial

burden on the nurse and her family that may arise from job loss or litigation cost

(Athanasakis,2019). According to Southwick, Cranley and Hallisy (2015), the sudden loss

of a loved one can put families under undue emotional and financial stress. The sudden

death leaves the family feeling lost and confused. Furthermore, the family tend to

develop a level of mistrust for the health system (Southwick et al., 2015). To avoid these

consequences, a registered nurse must comply with legislation, regulations, guidelines

and other standards when making decisions NMBA, (2018).

A reoccurrence of the nursing incident may be prevented by adopting evidence-based

approach to nursing practice, improved clinical communication, adherence to the 5 rights

of medication administration, continuous professional development training as well as

workload balance for nurses. Firstly, Nurses must provide safe and quality practice to

their patients in accordance with relevant policies and guidelines (NMBA, 2016).

Evidence based practice requires nurses to evaluate and critically analyse their decisions

before they are implemented (NMBA, 2018). In addition, improved communication

between clinicians is an essential factor in reducing medication error (ACQSHC, 2017).

The nurse should have checked with someone else to confirm the route for the

medication administration (Liu, Gerdtz, & Manias, 2016). According to Athanasakis

(2015) nurses must adhere to the 5 rights (right patient, right route, right time, right dose
and right documentation) in medication administration as non-adherence to it can have

fatal consequences. It is important that nurses undergo periodic training and Continuing

Professional Development (CPD). According to NMBA (2018) CPD is key to any

nurse’s ability to refresh knowledge and it’s also the basis for meeting learning

requirements that ensures nurses maintain competence to practise. It enables nurses meet

their obligation of providing safe and effective patient care. Additionally, workload for

nurses in the hospital environment should be balanced to prevent work-related stress that

may impair ability to critically reflect on tasks and also reduce chances of committing

medication error (Huckels-Baumgart & Manser, 2014).

Critical reflection plays an integral role in evidence-based nursing practice. When making

clinical judgements, nurses can critically reflect on variety of resources to improve the

quality of their decisions (Usher & Homes, 2017). This essay will adopt the Rolfe et al’s

reflective model, (Rolfe, Freshwater, and Jasper's (2001)). The incident saddened and upset

me because if the nurse had critically analysed her decision using the best available evidence,

the error that led to the patient’s death could have been avoided. After reflecting on the

incident, the nurse’s decision to administer the medication through a route other than the

prescribed one was unlawful. Due to the patient’s swallowing difficulty, the nurse might have

thought she was helping by crushing those tablets to aid ingestion. The nurse should have

adhered to the medication safety standard 4 of ACSQHC (2017) and also check with another

registered nurse on shift.

In conclusion, adopting evidence based nursing and critical reflection are two crucial

approaches to improve quality of practice and creation of a safe environment for patients.

Nurses must make conscious effort to apply these approaches in their practice. Nursing

incidences and their associated consequences in the example discussed can be greatly reduced

if nurses adhere strictly to all the standards and guidelines governing the administration of
nursing practice. At all times, nurses must continue to critically reflect on their actions,

maintain competency by attending trainings and regularly update their skills. The work

environment should be void of any workload related stress that may impair nurses’ ability to

make quality clinical judgements. Effective communication between clinicians should be

maintained to create opportunity to share knowledge and information. Critical reflection on

relevant standards and regulations will help nurses practice in an environment where patients

are safe.
 References

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