Medication problem situational examination

Patient, College student

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As a nursing student one thing that always appeared to come up in every lecture was medication errors and how to avoid them. The trainers would often go over the “five rights” of medicine administration. These kinds of medication government rights included the right patient, right medication, right dosage, right path, and best (Grissinger, 2010). As a pupil, one considers that medication errors is not going to happen within their career like a nurse, due to amount of that time period these rights have been protected in class. Nevertheless , according to Cheragi, Manoocheri, Mohammadnejad, Ehsani (2013), medicine errors had been made by 64. 55% of nurses, with most commonly becoming the wrong dosage or infusion rate as the mistake (p. 228).


My first experience with a medication error came early on in my medical profession. It absolutely was during a lysis case for a lower extremity profound vein thrombosis. For these cases we insert a catheter into the femoral artery and drip heparin and muscle plasminogen activator (tPA) near to the site of the clot for at least five several hours. Once the personnel hears the phrase tPA it causes wonderful duress and in addition they know they may be in for an extended case. This action is very extensive, stressful and time consuming while staff has to travel in several occasions during the night to evaluate how the clot is reacting.

Because my ayo and I had been setting up the first drips, pumping systems, medications and protocols to get the procedure to happen, I went to get the heparin out of the medicine dispenser. I went to the machine typed in the right medication and concentration. The drawer unveiled for me to grab the medicine. I confirmed it to my preceptor and your woman confirmed it absolutely was the right focus. We installed the medicines accordingly and transferred the sufferer to the rigorous care product for observation until we all returned later that night time. Upon come back, the doctor caring for our patient asked if we examined the medicine because it has not been the medicine concentration that was classified by the protocol. They were right, it was not the right concentration. It was basically less than what needed to be blended. Luckily enough, they had switched the tote and there is no harm done to the individual. As I went through this inside my head I was trying to figure out what happened. After several investigating we all found out the fact that pharmacy filled multiple concentrations of 4 heparin in the same cabinet. We hit with the safety team of the service and they realized that this was a hospital wide problem. After this event that they ended up certainly not stocking heparin in the same drawers and moved different concentrations to different dispensing units throughout the clinic.

Analysis of Situation Employing Ways of Being aware of

With medication mistakes nurses must be resilient in order to work through and pay attention to from their mistakes. In Polk (1997), steady acknowledgment of any situation could improve motion toward well being by providing a structure to get the hunt for the meaning of an experience. The usage of resilience being a nurse is vital in using the “ways of knowing”. Strength involves empirics, ethics, esthetics, personal and experience in the field of nursing in dealing with medication problems. I was capable of use empirics to understand that a certain attention of heparin must be used in order to be affective to lysis the clot. In Zander (2007), empirics is defined as using the technology of medical, concerning goal, and validated through repeated testing over time. The rate of infusion of heparin for a certain attention have been clinically verified in regards to what an effective dose is to help with lysis of the clot. In case the nurse that took over care of the patient had not noticed the medication mistake the clog would have not really been afflicted and the sufferer would have not had an great outcome.

Ethically, I actually do not consider my honest boundaries or principles were crossed, additionally , no one was harmed. Yet , I did feel ethically in charge of my problem because Some use the “five rights” of medication government correctly. Zander (2007), brings up ethical understanding is intended as an individual’s values and critical concern of precisely what is valued while one’s integrity, motives, and goals. Morally, I failed to cross any choices intentionally that afflicted my values or belief’s. However , this case did make myself more aware about moral questions and choices as I continue my practice as a great advance practice nurse.

Since I used to be a very green nurse, I used to be not able to present esthetic expertise because I didn’t have any prior experience with this sort of procedure. Zander (2007), cosmetic knowledge may be embedded inside the practices connected with nursing. With this situation, I was not familiar with this procedure and I bent on my preceptor for guidance to make sure I used to be doing the ideal thing plus the medications were correct. Although my ayo was a “seasoned” nurse I ought to have double check the protocol and made sure I was hanging the right medication , instead of taking somebody else’s word because of it. Now I was fully accountable for my own practice and will double and triple check in order to make sure a medication error like this doesn’t occur again.

In person, this case did take a cost on me personally and will stay with me throughout my medical profession. Let me always validate and validate medication and correctly make use of the “five rights” in my enhance practice. I actually am more aware of my “self” as well as the flaws it might consist of. In Zander (2007), personal knowing is an individual’s understanding rather than a personal way of understanding. I have learned from this experience so much. It will likewise be a regular reminder to me to increase and to develop as an advance practice nurse and be often reminded from the “five rights” and to always check and recheck when giving medications.

Zander (2007) associates breastfeeding experience while knowledge through frequent direct exposure. Since this was obviously a new procedure to me I had been unable to reflect on my experience. However , I will continue to gain more experience through my practice as being a nurse and taking graduate courses in order that medication errors are less recurrent. I do know which i am individual and errors will happen nevertheless by using the “ways of knowing” it will offer an improved way to work through my own errors towards a more cognizant and positive knowledge thus gaining my individuals as well as my own practice.

Reflection and Bottom line

Medicine errors occur in the career of nursing jobs, and there is no chance around it. A person can depend, validate and verify medications but man errors occur. Reflecting within this I noticed that the patient had not been harmed and that we were able to modify a hospital wide problem. The acceptance of changing a thing that affected the whole facility offered me enough sense that I don’t do anything bad for the patient and thankful one other nurse was there at the rear of me to evaluate my operate.

In Grissinger (2007), they state that the rights should be utilized as desired goals, and that to be able to achieve these types of goals that a strong support staff should be present to encourage safe techniques. I strongly agree with this statement in my medication error because without the support of the other nurses and administration this medication mistake could have removed a lot differently. However , i was able to change the practices with the hospital in order to avoid this by occurring to a new patient simply by moving several concentrations of heparin to different drawers of the medication dispenser. Through the “ways of knowing” I was able to reflect upon my medication error more thoroughly then before. Employing this has made me personally realize that mishaps and man errors take place. It provided me with a sense of relief that no one was hurt during the process and that my personal nursing knowledge will make me become a better advanced practice nurse.

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