Reflection: Learning from a Medication Error

Submitted by: Anonymous Adult Nurse working in an NHS acute hospital setting

What was the nature of the CPD activity and/or practice-related feedback and/or event or experience in your practice?

During a busy night shift on the medical ward, I was preparing medications for my patients. I had seven patients under my care, and it was approaching handover time. As I was drawing up insulin for a patient with Type 2 diabetes, I was interrupted twice by the call bell and a colleague asking for assistance. When I returned to complete the task, I nearly administered 10 units instead of the prescribed 8 units because I had lost my place in the process.

Fortunately, I caught the error during my final check before administration. I had to stop, take a breath, and start the entire process again from the beginning, checking the prescription chart carefully. The correct dose was then administered safely, and the patient experienced no harm.

What did you learn from the CPD activity and/or feedback and/or event or experience in your practice?

This experience taught me several important lessons about medication safety and the dangers of task interruption. I realised that my practice of trying to multitask during medication preparation was putting patients at risk, even though I believed I was being efficient.

I learned that safe medication administration requires my full attention and proper documentation at every stage. The incident highlighted how easily errors can occur when concentration is broken, even for experienced practitioners. I also recognised that I needed to be more assertive in managing interruptions during critical tasks.

Following this incident, I participated in our ward's medication safety audit and reviewed the trust's policies on medication administration. I also completed an online module about reducing distractions during clinical tasks, which reinforced the importance of creating a safe environment for medication preparation.

How did you change or improve your practice as a result?

Following this incident, I have implemented several changes to my practice:

• I now use a 'do not disturb' tabard during medication rounds to minimise interruptions
• I complete one patient's medications entirely before moving to the next, rather than preparing multiple doses simultaneously
• I have adopted the 'start fresh' rule - if interrupted during preparation, I dispose of what I've prepared and start again
• I've become more assertive in asking colleagues to wait unless it's an emergency
• I participated in our ward's medication safety audit and shared my experience (anonymously) to help others learn
• I volunteered to be a medication safety champion on our ward

These changes have significantly improved my medication safety practice. I feel more confident and less rushed during medication rounds, even on busy shifts. My colleagues have also adopted the 'do not disturb' approach, and we've seen a reduction in medication incidents on our ward.

Most importantly, I've learned that patient safety must always take priority over perceived efficiency. Taking an extra few minutes to prepare medications safely is far better than the potential consequences of an error.

How is this relevant to the Code?

This reflection relates directly to several aspects of the NMC Code:

• Section 1.4: Make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay - I learned that 'without undue delay' doesn't mean rushing at the expense of safety
• Section 10.1: Complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event - This applies to medication administration records and the importance of completing them accurately
• Section 13.2: Make a timely referral to another practitioner when any action, care or treatment is required - I recognised when I needed to seek support rather than trying to manage everything simultaneously
• Section 18: Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence, the law, our guidance and other relevant policies, guidance and regulations - This incident reinforced that safe medication administration requires full attention and adherence to proper procedures
• Section 19.2: Take all reasonable steps to reduce any potential for harm associated with your practice - Implementing the 'do not disturb' approach and the 'start fresh' rule are reasonable steps to reduce harm

Continuing Development

I plan to continue developing my practice by attending the trust's medication safety workshop next month and completing further online modules on reducing distractions during clinical tasks. I've also volunteered to mentor newly qualified nurses on our ward, sharing what I've learned about medication safety and the importance of creating a safe environment for practice.

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