Medication Error Situational Analysis and Reflection

Situation

My first experience with a medication error came early in my nursing profession. It was during a lysis case for a lower extremity deep vein thrombosis. For these cases we insert a catheter into the femoral artery and drip heparin and tissue plasminogen activator (tPA) near the site of the clot for at least five hours. Once the staff hears the word tPA it causes great duress and they know they are in for a long case. This procedure is very extensive, stressful and time consuming as staff has to come in several times during the night to check how the clot is reacting.

As my preceptor and I were setting up the initial drips, pumps, medications and protocols for the procedure to take place, I went to get the heparin out of the medication dispenser. I went to the system typed in the correct medication and concentration. The drawer released for me to grab the medication. I showed it to my preceptor and she confirmed it was the right concentration. We hung the medications accordingly and transferred the patient to the intensive care unit for observation until we returned later that evening. Upon return, the nurse caring for our patient asked if we checked the medication because it was not the medication concentration that was listed in the protocol. They were correct, it wasn’t the right concentration. It was actually less than what needed to be infused. Luckily enough, they had switched the bag and there was no harm done to the patient. As I went through this in my head I was trying to figure out what happened. After some investigating we found out that the pharmacy stocked multiple concentrations of intravenous heparin in the same drawer. We met with the safety team of the facility and they realized that this was a hospital wide problem. After this event they ended up not stocking heparin in the same drawers and moved the different concentrations to different dispensing units throughout the hospital.

Analysis of Situation Using Ways of Knowing

With medication errors nurses have to be resilient to be able to work through and learn from their mistakes. In Polk (1997), consistent acknowledgment of a situation could improve motion toward health by providing a structure for the exploration of the meaning of an experience. The use of resilience as a nurse is essential in using the “ways of knowing”. Resilience involves empirics, ethics, esthetics, personal and experience in the field of nursing in dealing with medication errors. I was able to use empirics to understand that a certain concentration of heparin must be used in order to be affective to lysis the clot. In Zander (2007), empirics is defined as using the science of nursing, concerning objective, and verified through repeated testing over time. The rate of infusion of heparin at a certain concentration have been clinically verified as to what an effective dosage is to help with lysis of a clot. If the nurse that took over care of the patient had not noticed the medication error the clot would have not been affected and the patient would have not had an ideal outcome.

Ethically, I do not believe my ethical boundaries or principles were crossed; in addition, no one was harmed. However, I did feel ethically responsible for my error because I did not use the “five rights” of medication administration correctly. Zander (2007), mentions ethical knowing is implied as an individual’s values and critical consideration of what is valued as one’s moral fiber, motives, and goals. Morally, I didn’t cross any choices intentionally that affected my values or belief’s. However, this situation did make me more aware of moral questions and choices as I continue my practice as an advance practice nurse.

Since I was a very green nurse, I was not able to provide esthetic knowledge because I didn’t have any previous experience with this type of procedure. Zander (2007), aesthetic knowledge can be embedded in the practices associated with nursing. In this situation, I was not familiar with this procedure and I leaned on my preceptor for guidance to make sure I was doing the right thing and the medications were correct. Even though my preceptor was a “seasoned” nurse I should have double check the protocol and made sure that I was hanging the right medication, instead of taking someone else’s word for it. Now I am fully responsible for my own practice and will double and triple check just to make sure a medication error like this doesn’t occur again.

Personally, this case did take a toll on me and will stick with me throughout my nursing profession. I will always validate and verify medication and correctly use the “five rights” in my advance practice. I am more aware of my “self” and the flaws that it might contain. In Zander (2007), personal knowing is an individual’s understanding rather than a personal way of perception. I have learned from this experience so much. It will also be a constant reminder to me to grow and to build on as an advance practice nurse and to be always reminded of the “five rights” and to always check and recheck when administering medications.

Zander (2007) associates nursing experience as knowledge through frequent exposure. Since this was a new procedure to me I was unable to reflect on my experience. However, I will continue to gain more experience through my practice as a nurse and taking graduate courses so that medication errors are less frequent. I do know that I am human and mistakes will happen but by using the “ways of knowing” it will provide an improved way to work through my errors in a more cognizant and positive experience thus benefiting my patients as well as my practice.

Reflection and Conclusion

Medication errors occur in the profession of nursing, and there is no way around it. A person can count, validate and verify medications but human errors occur. Reflecting on this I realized that the patient wasn’t harmed and we were able to change a hospital wide problem. The validation of changing something that affected the entire facility gave me enough sense that I didn’t do anything detrimental to the patient and thankful another nurse was there behind me to check my work.

In Grissinger (2007), they state that the rights should be used as goals, and that in order to achieve these goals that a strong support staff should be present to encourage safe practices. I firmly agree with this statement in my medication error because without the support of the other nurses and administration this medication error could have gone a lot differently. However, we were able to change the practices of the hospital to prevent this from occurring to another patient by simply moving different concentrations of heparin to different drawers of our medication dispenser. Through the “ways of knowing” I was able to reflect upon my medication error a little more thoroughly then before. Using this has made me realize that accidents and human errors occur. It provided me with a sense of relief that no one was hurt during the process and that my nursing experience will make me become a better advanced practice nurse.

Works Cited

1. Cheragi, M. A., Manoocheri, H., Mohammadnejad, E., & Ehsani, S. R. (2013). Types and causes of medication errors from nurse’s viewpoint. Iranian Journal of Nursing and Midwifery Research, 18(3), 228–231.
2. Grissinger, M. (2010). Reducing medication errors in nursing practice. American Journal
3. Institute for Safe Medication Practices. (2021). Medication errors. https://www.ismp.org/resources/medication-errors
4. Lamont, T. G. (2017). Medication errors: Don’t let them happen to you. Nursing Made Incredibly Easy!, 15(6), 18–23.
5. National Coordinating Council for Medication Error Reporting and Prevention. (2015). About medication errors. https://www.nccmerp.org/about-medication-errors
6. National Council of State Boards of Nursing. (2018). Medication errors.
7. Polk, M. M. (1997). Resilience and human response to chronic illness: Literature review. Journal of Advanced Nursing, 26(4), 800–805.
8. Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768–770.
9. Zander, B. (2007). Knowing and knowledge in nursing practice. Journal of Advanced Nursing, 60(2), 132–141.
10. World Health Organization. (2017). Medication errors: Technical series on safer primary care. https://www.who.int/publications/i/item/9789241511643