Introduction
We, as nurses, are constantly confronted with change, incidents, and avenues for exploration. As a nurse, you will have to implement new policies, overcome difficult client situations, and broaden your horizon on the path of this profession. This article will reflect on a particular incident of change experienced by the author, consider ways of preventing similar occurrences in the future, review pertinent literature, and relate my nursing philosophy and leadership motivation with theory. Continually enhancing care delivery by nurses takes place through manoeuvring through change/encounters/explorations
Incident Analysis
They stated directly after the mention of the medication errors that being on a high production medical/surgical unit practising, they once made a terrible medication error where an elderly patient was placed at high risk. The said patient was to receive a morning dosage of long-acting insulin for his unstable diabetes. In her tired and overworked state from overtime, the nurse on duty gave rapid-acting insulin to the patient, not comprehending how that sort of thing could be in such chaos—a characterization of the hospital’s medication storage system (Blouin, 2021). Shortly before the breakfast meal, the blood glucose of a patient who went to team members was found to be dropping critically low in a witnessed fashion.
The inspection points to several factors that have a great impact. Primary and foremost, the system applicable profile only applies one profile in the disposition, more so when it comes to the patient dosage formulation system, apart from the system. These used only one profile for both types of insulin that were utterly different in their working and dosage schedules. The application includes long-acting and rapid-acting insulin drugs labelled differently in the system. This reduces mistakenly taking the wrong insulin. There was, therefore, no necessity before the administering of the drugs. Even for life-endangering drugs such as insulin, the right dosage was not checked as per the MAR, and the pressure was put on the nurse to administer the wrong dosage of insulin. Calculating insulin doses by floated, untrained nursing shift included the intricate group of insulin doses administered to the patient. However, verification of such had to be rectified with more precision. An enduring new nurse would have revised the MAR and the order for insulin; she would have noted this deadly error way before the patient got this medication. A proper revision would have helped avoid this error as the doctor revising the MAR would have at least noted this deadly mistake and had it corrected way before the situation.
Lastly, the system-critical error implies that there is a systemic cause that human and system causes express the shortcomings of the safety standards applied. Applying the exhaustive 5 Whys root cause analysis, the root causes are insufficient safety devices, poor education, and unsafe unit culture. The 12-hour shift fatigue grabbed the wrong insulin in a dispensing system. Logically, the bifurcated system should entail labelling to avoid confusion when the two vials are placed together. The unit needed not to have extra checks over drugs, which can prove hazardous to the patient. Other occurrences have occurred in other caregivers, needing to take place or not verifying the handoff of insulin kinds, thereby causing the rushed and unsafe handoff of insulin. The implementation of safety mechanisms overall was not based on regulation due to a lack of oversight of pharmacists, managerial control, educational hitches, and inculcation of a safety culture.
This presents a check, and the response must be radical. It should lead to a wide change in the system toward a better way of studying nursing, higher numbers of staff, and practice of higher standards together with accountability. All that must be accomplished through a comprehensive, evidence-based approach that will see the bridging of those gaps.
Prevention
Some of the broad-level initiatives that can be taken to make sure such a hazardous mistake is not repeated relate to the outdatedness of the medical dispensing system, such that the long-acting insulin will henceforth always be of a disparate colour and labelling from short-acting insulin to alert the medication type and doses (Liukka et al., 2020). Apart from that, different prominent characters would be placed on the contrasting lettering, introducing similar insulins. Besides that, the system should be required to check for redundancies in cases of overrides, many side effects in the drugs, and patients with complex cases.
Standardizing a double-check system for administering all high-alert medications will add another layer of safety valves for administration. A general % reduction in errors with medication of 50% is stated for vulnerable patients in which independent double-checks are reduced with verbal confirmation. To make this checkup effective, it should be formalized and structured with a doctor or nurse to state the name of the drug, the specific dose, the route, if the patient has any known allergies, and all patient identifiers before giving the injections.
There is also the need for considerable improvement in nursing handoffs in the field of continuity of care and safety in medication. The normalization reporting of controlled substances via verbal medication reconciliation and verification should lead to the memory of information between and the outflow of information to another nurse. Teach-back technique methods should be built to confirm the truthfulness of the word handoffs between nurses.
Strongly advocating for a safety culture right to the hospital walls is basic. Intensive education, non-punitive events, and reporting safety huddles, intensive analysis of the event should become the norm carved within the system to help joint accountability prevail (Liukka et al., 2020). Such nurses and other employees should be called upon and queued immediately to call out alerts and safety concerns in case they come around such problems. The partnering provider and the pharmacists’ integration would be of great value. Lastly, we take responsibility for safety down to the top management, transparency, and error removal right at the core of the most critical components to process improvement en mass.
Data Analysis
Including nursing literature would provide an evidence base for clinical practice that would improve patient outcomes. A few research papers have indicated that information systems contribute to positive outcomes in patient safety and quality of care when used carefully. An integrated literature review showed a direct association between the use of EMR and reductions in adverse drug events, medication administration errors, and treatment delays (Choudhury & Asan, 2020). However, the benefits depended on the context and how the customization and clinical input were the keys to their successful design and implementation. EMR-based nursing handoff tools standardized communication and reduced sentinel events when properly trained. Literature data analysis profiles how health IT systems can support nursing work by providing aids to evidence-based decision-making and enhanced care coordination. However, a particular emphasis is that automation introduces new problems such as alarm fatigue. Effective IT systems integrate clinical knowledge and enhance functionality to deter any uses for replacing human effort (Choudhury & Asan, 2020). Research reviews these benefits and likely pitfalls of implementing health information systems. The reviews offer strong data to guide the ideal design for the system in driving knowledge-based nursing practice.
Nursing Context
Watson’s Theory of Transpersonal Caring: Regarding my nursing philosophy, this is the theory I can relate to most. It highlights the transpersonal relationship between nurse and patient, holistic care, and nurturing individuals. These values epitomize human connection and support for well-being apart from physical health. Nursing is about tasks and technology and knowing patients as persons (Kachaturoff et al.,2020). Watson articulates nursing as a science and art by balancing compassion and competence. I intend to merge them in my work by creating relationships with patients, educating them so they can make informed decisions on their healthcare choices as well as incorporating social-emotional needs into the medical treatment plan.
Nonetheless, full attention to holistic caring can sometimes be overshadowed by a lack of time or administrative duties. This theory reminds me of focusing back on the human aspects of care. Her concept includes creative factors such as forming a helping-trusting relationship, which serves as an ethical guide. The focus will always be centred on human needs because nursing practice evolves.
Regarding nursing leadership inspiration, I look up to Jean Watson. Besides her famous theory that has greatly influenced the field philosophically, she established Watson Caring Science Institute to promote…
Conclusion
In healthcare, progress is dependent on change, though change offers a chance for improvement. I have developed resilience and adaptability as a nurse from my experiences adjusting to major changes like EMR system adoption. To maximize success in implementing change, it is important to consider evidence-based strategies that promote this process. In the ever-expanding scope of technology and knowledge, reviewing literature data proves instrumental in learning at nursing’s frontiers while grounding practice within core ethical foundations. My approach to nursing care at the bedside and leadership has continued to be inspired by Watson’s philosophy on science balancing with humanity. It will be up to brave nurses who learn continuously, embrace change fearlessly, and provide holistic care to pave the way into the future. The goal for every nurse at whatever level should be compassionate excellence aimed at improving patient outcomes so that we can save lives, ultimately – enhance patient outcomes, and advance the field as a result of saving lives.
References
Bressan, V., Mio, M., & Palese, A. (2020). Nursing handovers and patient safety: Findings from an umbrella review. Journal of Advanced Nursing, 76(4), 927-938. https://doi.org/10.1111/jan.14288 (Nursing journals should be three)
Choudhury, A., & Asan, O. (2020). Role of artificial intelligence in patient safety outcomes: systematic literature review. JMIR medical informatics, 8(7), e18599. https://preprints.jmir.org/preprint/18599?__hstc=102212634.fbb6422956a6b55e7922d429a12908aa.1708612588859.1708612588859.1708612588859.1&__hssc=102212634.1.1708612588859&__hsfp=2937381479
Cummings, G. G., Lee, S., Tate, K., Penconek, T., Micaroni, S. P., Paananen, T., & Chatterjee, G. E. (2021). The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership. International journal of nursing studies, 115, 103842. https://doi.org/10.1016/j.ijnurstu.2020.103842
Kachaturoff, M., Caboral-Stevens, M., Gee, M., & Lan, V. M. (2020). Effects of peer-mentoring on stress and anxiety levels of undergraduate nursing students: An integrative review. Journal of Professional Nursing, 36(4), 223-228. https://doi.org/10.1016/j.profnurs.2019.12.007
Mulac, A., Taxis, K., Hagesaether, E., & Granas, A. G. (2021). Severe and fatal medication errors in hospitals: Norwegian Incident Reporting System findings. European Journal of Hospital Pharmacy, 28(e1), e56-e61. https://ejhp.bmj.com/content/28/e1/e56?int_source=trendmd&int_medium=cpc&int_campaign=usage-042019
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