I am reflecting on an experience which I experienced in my clinical practice. I will use Gibbs reflective cycle which has different stages such as description, feeling, evaluation, analysis, conclusion and action plan to reflect on a professional learning experience which was incomplete documentation. Documentation is the written and legal record of a patient’s care and a completion of health related data (Dempsey ; Wilson, 2009) Medication error is a life threatening and frequently reported errors in health care system in Australia. According to Medication Safety in Australia an Overview (2009), medication error prolong the hospital stay of approximately 190,000 patients each year. During my placement, I was working with one of the registered nurse in a hospital ward. When I was taking routine vital signs, one of the patient complained headache. Then, I informed to the registered nurse. The patient was on routine and PRN Panadol. Panadol is an analgesic and antipyretic which is used to relieve pain from headache, backache, toothache and osteoarthritis as well as fever from cold and flu (Lehne, Moore, Crosby, ; Hamilton, 2013). When I checked medication chart after taking routine observations, I observed that the nurse overdosed the Panadol. The maximum dose of the Panadol for the patient was 2gm per day. Patient had already 2gm including routine and PRN dose Panadol on that day in previous shift but the nurse overdosed 1gm.
This critical incident made me feel worried because overdose of Panadol can lead to serious adverse effects to the patient such as nausea, vomiting, gastrointestinal bleeding, and hepatic encephalopathy, hepatic toxicity, permanent liver damage as well as it may result the death of the patient (Cheragi, Manoocheri, ; Ehsani, 2013).
I insightfully evaluated this incident and learned an important of checking the medication chart thoroughly following five rights of medication administration. Medication administration is not simply the administering the prescribed drug to the patient. It is the safe practice of administering drugs to patients following principle of five rights such as the right patient, the right drug, the right drug, right dose, the right time and the right route (Medication Handling in NSW Public Health Facilities, 2013). I also experienced that nurses should carefully check the medication order including PRN dose, form, route of administration and the time for the administration including previous administration time to prevent from overdose. By evaluating the incident, I also noticed that nurses was on double shifts. Cheragi, Manoocheri, ; Ehsani, (2013) stated that medication errors more likely occur from the nurses due to tiredness, careless, high workload, stress, poor communication and deficit of knowledge and skills as well as who work long hours shifts (more than 8 hours). On that day, the nurse told me that she was working double shift at that afternoon. I observed that nurse was tired and rushing to administer the medication so she did not check the medication chart thoroughly including PRN dose. She was busy with other routine work at ward. She was getting late and rushing to carryout routine medication to the patients.
By analysing the incident, I learned that as a nurse we should know the duty of care as well as the patient safety. Nurses are responsible for patient safety while administering the medication because they are final point of contact. So, nurses should double check the prescription, administration and documentation of each medicine before administering the drug to the each patient. To prevent the similar incident and get the better outcome, the nurse should have thoroughly checked the medication chart including PRN and maximum dose Panadol that patient can take. She could have double checked medication chart after administering and before signing the medication chart. That could help to start the reversal dose of Panadol by informing doctor as soon as possible. In addition, if she was tired working double shift and rushing with high workload, she could have asked her co-worker to help administer Panadol.
As a result of this incident, I realised that nurses should attend an education and training to be a competent and confident nurse to perform safe medication administration practice for patient safety (Nursing ; Midwifery Board of Australia, 2010). Nurses should also require education on how to handle workload and prioritise the tasks for the patient safety and to deliver the quality of care to patients. Moreover, they should follow the safe medication practices such as five rights of medication administration as well as they should know the pharmacokinetics of drug before administering such as dose, route, frequency, side effects of drug. Nurses should know important of the five rights of medication administration even though they are in the busy working situation and should not rush to while administering drug to prevent medication errors. Nurses should also double check routine medication order as well as PRN dose thoroughly before administrating of medication to prevent medication errors as well as to deliver the quality of care to patients.
I am reflecting on an experience which I experienced in my clinical practice. I will use Gibbs reflective cycle which has different stages such as description, feeling, evaluation, analysis, conclusion and action plan to reflect on a professional learning experience which was incomplete documentation. Documentation is the written and legal record of a patient’s care and a completion of health related data (Dempsey & Wilson, 2009). On the last day of clinical practice, we, all morning shift nurses were taking a handover from night shift staffs, they discussed about incomplete documentations of the type of dressing applied on the 20 % hot water burned wound. According to the night staffs when they checked every patient as well as the dressing on the wound, they found one patient without dressing on the burned area. The dressing was taken off by the patient. Then, they tried to put the dressing, it became hard for night staffs to choose the dressing which was applied in the morning by morning staff. During my three weeks placement, I noticed that different types of dressing are applied on the burned area according to the stages of wound healing process. That is why it is very important to record the type of dressing that is applied especially on the burned wound.
After completion of handover from night staffs, it made me feel neglected because documentation is very important. It communicates with other health care providers, ensures continuity of care, supports evaluation of quality of patient care as well as it serves legal documentation (Dempsey & Wilson, 2009). In addition, poor documentation can negatively affect professional accountability, organizational risk and more importantly, holistic patient care (Blair & Smith, 2012).
I insightfully evaluated the purpose of documentation and learned nursing documentation should provide detail, accurate and complete information because it provides the vital and comprehensive picture of patient’s status. Nursing documentation clearly and concisely communicates to other health care professional about the patient’s status, nursing intervention and outcomes of intervention (Paans et al., 2010). Moreover, it informs health care professionals whether patient is making progress towards excepted outcomes or not which facilitates to change the care plan of the patient to improve the patient status. By evaluating the reason of incomplete documentation, I was informed that the nurse was busy. There were two Medical Emergency Team call during her shift. Nurses more likely document incomplete information due to lack of time, tiredness, careless, high workload, stress, poor communication and deficit of knowledge and skills (Blair & Smith, 2012).
By analysing the situation I learned that as a nurse, we should know the duty of care and the purpose of documentation on the patient record. Nurses are responsible for ensuring that all therapeutic orders are entered in the patient records and implemented to make sure to provide the right and effective treatment which can minimise the hospital stay for the patient (Marinis et al., 2010). So, nurses should thoroughly double check each patient’s record to ensure all the vital information are documented to get an expected and better outcome for patients In addition, if the nurse was busy with high workload, she could have asked her co-worker to help other routine works and complete the documentation.
As a result of this situation I realised that nurses should be a competent and confident nurse to perform duty of care to deliver the quality of care for the patient. According Nursing ; Midwifery Board of Australia (2010) nursing documentation is a part of professional responsibility which evaluate standard of nursing care as well as it is a principle source of information. So, nursing documentation is an essential component to maintain a competency standard of nursing practice. If nurses lack the knowledge and skills to provide accurate, complete, concise and comprehensive information on patient’s record, they should seek assistance from expertise such as documentation education and training to improve the quality of nursing documentation (Paans et al., 2010). Nurses should also require education on how to write accurate, complete documentation in timely and organised manner, and prioritise the tasks to deliver the quality of care to patients. Nurse should also know the purpose and importance of documentation. Nurses should thoroughly double check the patient’s record to ensure all the vital information are documented to provide an appropriate treatment and achieve the expected outcome as well as to deliver the holistic and quality of care for the patient.