Clinical incident Essay Example

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Nursing Case Study – Clinical Incident S8 Medication

Question 1. Provide a concise description of the incident (i.e, what happened?)

 Your answer is to go here.

One newly registered nurse was doing a placement in the Coronary Care Unit in one of the morning shift when a medication error incident happened. In that morning shift, the newly registered nurse was working with another registered nurse, Mary, who was attending to different patients but in the same ward. The two registered nurses were doing their rounds and were supposed to administer S8 medication to their respective patients when Mary suggested that the newly registered nurse do an S8 check with her to which the newly registered nurse obliged. With the S8 book and medication chart with them, Mary proceeded to pick the two drugs, Endone 5mg and Targin 5/2.5, and made the required tablet count and placed them in two separate medication cups. While Mary took the medication chart for each specific patients after picking the tablets, the newly registered nurse carried both cups containing the two drugs to proceed to administer them to the patients. The two nurses proceeded to Mary’s patient where they did the patient checks and three drug checks after which the newly registered nurse handed over the drug in one of the cups to Mary’s patient. The patient proceeded to swallow the tablet with water before Mary and the newly registered nurse both signed the S8 book to ascertain that the patient had taken the drug. Thereafter, the two nurses went into other patient’s room and did the patient identification and drug checks only to realise that the newly registered nurse had given Mary’s patient Targin 5/2.5mg instead of Endone 5mg which was supposed to be given to the newly registered nurse’s patient.

Question 2. Identify the relevant factors in the clinical context that potentially

contributed to the incident (i.e., why did it happen?)

 Your answer is to go here.

One of the factors that may have contributed to the medication error is the interruption caused by the fellow nurse. The newly registered nurses co-administered the medication to Mary’s patient while in company of Mary. This was not the plan and in so doing the newly registered nurses ended up administering the wrong medicine to Mary’s patient. The involvement of Mary in administering the medication by the newly registered nurse may have interrupted or destructed the newly registered resulting in a mix up of the medication to be administered to Mary’s patient. Hayes, Jackson, Davidson & Power (2015) identified that interruptions are among the leading source of medication errors and that they can potentially be life threatening to the patient and even the family member of the patient. Even though some interruptions such as patient alarm signalling deteriorating care are welcomed and important, some such as during the administration of medication have resulted in patient harm before (Johnson et al., 2017). Other studies such as Westbrook & Li (2013) also suggest that interruptions or destructions by other activities or staff have been significantly linked to medication errors as it may have been the case in this case study outlined. Cloete (2015) also assert that interruptions especially during the stage of medication administration are a significant cause of medication errors and minimization of these interruptions can lead to a reduction in medication errors during medicine administration stage.

It is also possible that the institution lacked the relevant policies and procedures that limit or proscribe interruptions or destructions during medication administration as is required in Standard 4 of the National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2012). Presence of such policies and enforcement of the same can be instrumental in limiting interruptions and such medication errors as reported by Cloete (2015).

Apart from the destruction or interruption, since Mary was a qualified registered nurse who was more experienced than the newly registered nurse, she was supposed to work with the newly registered nurses as a team and not work in isolation. Even though the newly registered nurse was administering medication to Mary’s patient, Mary did not crosscheck or double-check, or support the newly registered nurse in identifying the right medication for Mary’s patient. The error may have been prevented if Mary had double-checked the medicine to ascertain that what was to be administered was what was right and required by the patient (Hardemeier, Tsourounis, Moore, Abbott & Guglielmo, 2014).

Another potential cause of the identified medication error is that the newly registered nurse may not have adhered to the six medication administration rights. The newly registered missed to confirm whether the right drug was being administered to the right patient. The nurse correctly identified the patient but failed to confirm whether the drug to be administered was the right drug for the patient before administering the drug as explained by Elliot & Liu (2010). If the newly registered nurse was unsure of the medication that was to be administered, it is appropriate that the nurse would have enquired or sought clarification from a Pharmacist or gone to confirm the drug from its package (Elliot & Liu, 2010). The newly registered nurse failed to recognise the right medicine for Mary’s patient and only realised when it was already late that the wrong medicine had been administered to Mary’s patient. If the nurse could have confirmed that the drug administered to Mary’s patient was the right one, the error would not have occurred.

In so doing, the newly registered nurse failed to provide safe and quality nursing care to Mary’s patient as required by Standard 6 of the practice standards for registered nurse in Australia (Nursing and Midwifery Board of Australia [NMBA], 2016).

Question 3. If you were involved in a similar clinical situation in the future,

what alternative actions would you take? (i.e., what would you do differently?)

 Your answer is to go here.

In future, to limit the occurrence of such clinical incidence, I shall remember to keep into consideration the necessary six medication administration rights optimally which include the right patient, right drug, route, dose, time, form and right documentation of medication as explained in Elliot & Liu (2010). If in doubt of the identify of medication from its appearance, I will go back and confirm the identify from its packaging so that am sure the medicine prescribed for a patient is rightfully administered by the patient. In addition, I shall minimise or limit destructions when performing medication administration because that’s what may have precipitated the medication errors in this case study. I shall undertake my nursing responsibility one at a time and will also label my medication can with the respective patient identity so that each medication can containing any drug Is identifiable by the name of the patient who is to receive the specific drug. In addition, I shall always compare the medication to be administered to the medication administration record or the electronic version before proceeding to administer it (Hardemeier et al., 2014).

In addition, if working with another registered nurse assisting in providing nursing care., I shall take an active role and work as a team with the registered nurse. I shall doublecheck the medication to be administered by the registered nurse just to be sure that what was been administered was the right medicine for the patient.

Such errors would also have to be reported so that they can inform the institution to develop policies towards minimization of such errors. This include the requirement for medication double check if nurses are working together in a shift. (Cloete, 2015).


Australian Commission on Safety and Quality in Health Care. (2012). National Safety and Quality Health Service Standards 2012. Canberra: Australian Commission on Safety and Quality in Health Care.

Cloete, L. (2015). Reducing medictaion errors in nursing practice. Nursing Standard
, 29 (20), 50-59.

Elliot, M. & Liu, Y. (2010). The nine rights of medication administration: an overview. British Journal of Nursing , 19 (5), 300-305.

Hardmeier, A., Tsourounis, C., Moore, M., Abbott, W.E., & Guglielmo, B.J. (2014). Pediatric medication administration errors and workflow following implementation of a bar code medication administration system. Journal for Healthcare Quality , 36 (4), 54-63.

Hayes, C Jackson, D Davidson, PM & Power, T. (2015). Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. Journal of Clinical Nursing
, 24 (21-22), 3063-3076.

Johnson, M., Sanchez, P., Langdon, R., Manias, E., Levett-Jones, T., Weidemann, G., Aguilar, V. & Everett, B. (2017). The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of nursing Management .

Nursing and Midwifery Board of Australia. (2016). Registred nurse standard for practice. Melbourne: Nursing and Midwifery Board of Australia.

Westbrook, J. & Li, L. (2013). Interruptions are significantly associated with the frequency and severity of medication administration errors. Research in Nursing & Health , 36 (2), 116-119.