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Clinical Reflective Journal

Weiga Chen

School of Nursing, Trent University

NURS 3021: Clinical Practice Focused on Chronic Disease Management

Clinical instructor: Jovette Pinet

May 27, 2022

Clinical Reflective Journal

The incident that I would like to reflect on is the medication error I made this semester.

The incident happened during the 3rd week of the clinical on F5 of Lakeridge Hospital. A patient

needed 12.5 mg of metoprolol to help control her blood pressure; however, because of my

mistake, 25 mg of metoprolol was administered instead.

I realized the mistake when I was documenting the medication administration with my

clinical instructor. In the beginning, I could not believe I had made the mistake because we had

checked three times as per the protocol. And then, I felt overwhelmed and nervous about what

would happen to the patient and what would happen to my career. I always think of myself as a

meticulous and detail oriented person, and this incident broke my understanding.

After the incident, the PCN, the physician, the charge nurse, and the patient were notified

immediately. Patient was monitored closely with blood pressure and daily activities. No adverse

impact was observed, and the patient reported no discomfort. Since reporting of errors and near

misses is an entry to practice expectation related to professional responsibility and accountability

of the College of Nurses of Ontario (CNO, 2019), a report was also submitted to the school

under the guidance of the clinical instructor as per policy after the incident.

Freeman et al. (2020) identified ten contributing factors to student nurses medication

incidents, including patient information; drug information; communication; drug name, labeling,

and packaging; drug storage and availability; drug delivery device; environmental and human

limitations; competency and education; patient and family education and engagement; policies

and procedures. As indicated in the report, factors such as the drug delivery devices and policies

and procedures are involved in this incident. For example, both EMAR and ADU did not put

enough emphasis on the need that the pill has to be splitted and the ADU not showing the correct
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dose. In addition, the rover is not available to the instructor and me, and therefore the medication

cannot be scanned at the bedside which greatly increases the likelihood of medication errors.

Despite the fact that additional factors also contributed to this incident, I, as a nursing student

who is still learning, should have been extra careful during medication preparation and

administration. While I feel relieved that the patient is safe, because of this incident, I learned to

be extra careful when preparing medication including paying attention to instructions written in

smaller fonts and I have not made any more mistakes since then.

Aside from reporting the incident and suggesting ways that the organizations could

improve on to promote patient safety, I also recognize that the ‘12-rights’ and the ‘3-checks’ are

not just for exams but are very important in minimizing chances of medication errors and

preventing injuring the patients. The 12 rights of medication administration include right patient,

right dose, right time, right route, right site, right date and time, right frequency, right

documentation, right patient, right to refuse, right reason, right education (Potter et al., 2013;

Lermontov et al., 2019). The three checks include comparing the ADU against the MAR,

comparing the medication taken out of the ADU against the MAR, and checking the medication

against the MAR at the bedside. This incident is a very important learning for me because I will

always remember this incident and be extra cautious with medication administration in my future

practice.
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References

College of Nurses of Ontario. (2019). Entry-to-practice competencies for registered nurses.

https://www.cno.org/globalassets/docs/reg/41037_entrytopracitic_final.pdf

Freeman, M.A., Dennison, S., Giannotti, N., & Voutt-Goos, M.J. (2020). An Evidence-based

framework for reporting student nurse medication incidents: Errors, near misses and

discovered errors. Quality Advancement in Nursing Education, 6(3).

https://doi.org/10.17483/2368-6669.1233

Lermontov, S., Brasil, S. & de Carvalho, M. (2019). Medication errors in the context of

hematopoietic stem cell transplantation. Cancer Nursing, 42 (5), 365-372. doi:

10.1097/NCC.0000000000000613

Potter, P.A., Perry, A.G., Ross-Kerr, J.C., Wood, M.J., Astle, B., & Duggleby, W. (Eds.). (2013).

Canadian fundamentals of nursing (5th. Canadian Ed.). Toronto ON: Elsevier Canada.