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Critical Medication Incident Reflection


Reflection is an essential and necessary skill for all health care professionals and is also in line with (NMBA, 2017). Reflective practice ensures continual learning and enables health practitioners to improve their practice as it encourages self-evaluation (Murdoch, 2019). Reflection also aids in discovering beliefs, values, and information ingrained in experiences (Sorrell, 2017). Gibbs’s reflective cycle has been chosen because it is easy to use. Also, encourages a detailed account of the circumstances, assessment of the feelings and experience, analysis to make sense of the experience, conclusion where other options are taken into consideration, and reflection on the experience to consider what one would do if the circumstance arose again (Ardian, Hariyati, & Afifah, 2019). The incident was a miscommunication incident between nurses that resulted in the patient being given double doses. This incident was selected because it made the nurse aware of his shortcomings and those of other team members, which caused him to dwell on the incident and consider what lessons could be drawn from it to avoid repeating the same error.

Additionally, according to Billstein-Leiber et al. (2018), communication is necessary for nursing practice as it underpins quality healthcare, patient satisfaction, and the realization of favorable health outcomes. As directed by the Gibbs reflective cycle, the incidence will be described briefly; the nurse’s feelings and why the incidence is essential to nursing practice will be discussed. Later an action plan will be formulated to ensure the nurse handles the situation better if it occurs again. Confidentiality is essential to reflection; therefore, the patient will be referred to as (Rose, not her real name).


Rose was a 23-year-old female admitted to the hospital for colorectal surgery. Rose’s prescription included a dose of paracetamol three times a day. As the team leader, I was supposed to oversee other nurses and patient care transitions. Therefore I went through hand-over charts between shifts. As I did the PCA checks and obs at 1701 hrs, I noticed there was an IV paracetamol that was still clamped. I cross-checked the medication chart and realized that the paracetamol IV was ticked at 1638 hours. Since it was only 30 minutes later, I assumed my partner had forgotten to unclamp the IV medication, so I unclamped it. After one hour, I noticed the IV, approached me, and told me that the morning shift nurse had left the IV medication unadministered. Hence, she decided to administer oral paracetamol. This is where I realized that the patient had received a double dose of paracetamol. We decided to recommend that Rose undergoes Liver function tests. Rose’s paracetamol levels were slightly raised, but below the treatment requirement, so we monitored her for a few hours. I also went ahead and changed the administration time and indicated in the charts the drugs administered.


I was anxious and worried about making mistakes when assigned the leadership position. However, I was able to overlook the fear and perform my responsibilities. According to Wondmieneh et al. (2020), those who experience medication errors often experience emotional distress and a lack of confidence. When this incident occurred, I felt discouraged and doubted my clinical skills. I was angry that my partner did not communicate that she administered oral paracetamol but indicated in the chart that it was an IV. I felt disturbed and sad about the double dosage. I feared losing my job and facing litigation due to the error. I feel I dealt with the situation with outward calm and in a professional manner that ensured the patient’s safety. In the end, I was very pleased Rose’s situation did not worsen, and she recovered without further complications.


The experience was good because the patient was not seriously affected by the double dosage error. In addition, because my partner and I communicated immediately after the symptoms were exhibited, we could start a reversal treatment immediately; hence the patient did not develop liver sepsis. However, I worked on the assumption in this situation when I could have asked my partner. If I had asked her, the medication error could have been avoided. The patient experienced side effects because of the double dosage. I failed to adhere to all seven rights (7rs), the right patient, medication, dose, route, time, Response, and documentation (Jones & Treiber, 2018). As a result, the patient was negatively affected. Proper documentation of medication can aid prevent medical errors from occurring within the hospital (Wheeler et al., 2018). However, in this case, there was no proper documentation by the morning shift nurse and my partner, which prevented me from assessing relevant information.

In addition, I did not adhere to the recommended medication adherence practice. Hospital staff must report all incidents they observe or errors they make. Therefore by involving the Chief Medical officer, risk man, and Manager, I was adhering to the policies and regulations of the hospital; hence the case was managed efficiently in line with this, and the LFT levels were checked immediately. This was good because the patient was monitored for any evidence of an adverse reaction.


Medical mistakes are rarely the result of careless or inexperienced medical personnel. Instead, they frequently result from a breakdown in the procedures that control how patient care is delivered (Sorrell, 2017). Medication errors often occur in the administration phase (Wondmieneh et al., 2020). Therefore effective communication is essential in this phase. Teamwork requires cooperation, communication, and coordination between members of a team. My partner and I failed to communicate effectively in the team dynamic in this incident, and hence Rose suffered. Shitu et al. (2018) discovered that effective interdisciplinary communication is a prerequisite for providing high-quality healthcare. Rose’s safety was reduced by ineffective communication between staff. Shitu et al. (2018) further suggest that other medication errors can be avoided through effective communication between the nurse and the patient. Involving the patient in medication management could have prevented the double dosage. Rose could have informed me about the Oral medication she had received from my partner.

According to the (NMBA) (2017), when Registered nurse delegates tasks, they should ensure they supervise the practice to ensure that delegated practice is safe and correct. However, as the leader, I failed to adhere to this direction; I did not supervise the work done by my partner. Morover, Hanson & Haddad. (2021) have argued that nurses should not “blindly” give medications; instead, they should seek clarification when needed. In addition, Rodziewicz et al. (2022) advocate for double-checking before medication administration. I, however, administered Rose’s medication blindly, guided by my assumption rather than confirming facts. I should have double-checked with the patient medication chart to ensure that the correct dose of medication is administered to the patient at the right time (Rodziewicz et al., 2022). This medication error was avoidable if I had gone through the patient medication chart carefully before administering it and communicated with my partner before deciding to administer it. Therefore, it can be said that such situations happen due to a lack of communication and lack of proper documentation concerning patient care.

When I realized the patient had received a double dose of the medication, I immediately informed the Chief Medical officer (CMO). I made this decision because nurses have an ethical obligation to help prevent and manage medical errors (Sorrell, 2017). Therefore by reporting, I was putting the patient’s concerns first and fulfilling my ethical obligation. In many circumstances, however, nurses do not report errors because of fear of litigation (Rodziewicz et al., 2022; Sorrell, 2017; Wondmieneh et al., 2020) ). I was aware that the double dose of the medication posed a substantial threat to patient safety. therefore, by testing the LFT levels, I was also fulfilling my ethical principle of Beneficence and Non-maleficence (Sorrell, 2017) by taking the necessary steps to minimize the harm caused by an error. In line with this, I should have informed Rose of the error. For instance, if the levels were significantly raised and I failed to inform her of the error, she may have refused the additional treatment required to reduce the rising levels.


To avoid this situation, I would double-check the medication chart and communicate with the nurse that was supposed to administer the medication. In addition, I would never administer medication that I have not prepared or helped prepare. If there is any uncertainty over any aspect of medication, I should consult with the nurse in charge and, if need be, the prescribing officer. In other circumstances, I would also consider the patient’s current condition when administering drugs. For instance, Rose was not exhibiting any signs of pain in this circumstance, which should have prompted me to ask my partner about the pain medication instead of directly administering it. It is also essential for a nurse to the rationale for the drug administration. Considering the reason for administration would ensure an overdose or medication error is not made. For instance, in this case, the reason for administration was based on an assumption instead of a viable reason.

Action plan

Miscommunication by different parties was the leading cause of medication error in this incident. Therefore if put in a leadership position, I would organize a safety talk around the facility I am posted to ensure nurses are educated on the importance of double-checking medication and making the correct documentation. Drug administration guidelines ensure that nurses will not repeat the same mistake. The nurses would be educated that medication administration should be clearly and accurately recorded immediately. And if a drug was not administered deliberately, it should also be documented. My partner should have documented the unadministered IV and the administration of the oral paracetamol; hence such a proram would educate her. the program would also encourage sharing Stories of Errors rather than keeping mistakes hidden because of fear and hearing other people’s stories. Other staff members can prevent and/or manage healthcare errors by being aware of how others have handled errors or wish they had managed them differently.

In addition, I will undertake an online leadership course to ensure that I am equipped to create an environment where my team members can collaborate and communicate efficiently. I believe the course will equip me with the skills to respectfully hold others within the team accountable. Additionally, I will be more cautious while dispensing medication in my future practice by carefully checking medication charts. I will always follow the medicine checks, time, and seven rights. In a leadership position, I would also design Checklists, Reminders, and Double Checks to reduce medical errors, especially when errors are likely to occur.


Ardian, P., Hariyati, R. T. S. & Afifah, E., 2019. Correlation between implementation case reflection discussion based on the Graham Gibbs Cycle and nurses’ critical thinking skills. Enfermería Clínica, 29(2), p. 588–593.

Hanson, A. & Haddad., L. M., 2021. Nursing Rights of Medication Administration. StatPearls.

Jones, J. H. & Treiber, L. A., 2018. Nurses’ rights of medication administration: Includingauthority with accountability and responsibility. Nursing Forum, 53(3), p. 299–303.

Murdoch, M., 2019. How to reflect on your practice for revalidation. Nursing in practice.

Nursing and midwifery board Aphra, 2017. Registered nurse standards for practice. [Online] Available at:

Rodziewicz, T. L., Houseman, B. & Hipskind., J. E., 2022. Medical Error Reduction and Prevention. StatPearls [Internet].

Shitu, Z. et al., 2018. Avoiding Medication Errors through Effective Communication in Healthcare Environment. Movement, Health & Exercise, 7(1), pp. 113-126.

Sorrell, J., 2017. “Ethics: Ethical Issues with Medical Errors: Shaping a Culture of Safety in Healthcare .”OJIN: The Online Journal of Issues in Nursing, 22(2).

Wheeler, A. J., Scahill, S., Hopcroft, D., & Stapleton, H. (2018). Reducing medication errors at transitions of care is everyone’s business. Australian Prescriber, 41(3), 73–77.

Wondmieneh, A., Alemu, W., Tadele, N. & Demis, A., 2020. Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing.


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