Making Use of the Gibbs Model for Evaluating Medication Error - Essay Example

? Reflection Paper on Medication Error Making Use of the Gibbs Model for Reflection Table of Contents I. Introduction 3 II. of Event- Phase One 5 III. Feelings – Phase Two 7 IV. Evaluation- Phase Three 8 V. Analysis- Phase Four 9 VI. Conclusion- Phase Five 10 VII. Action Plan- Phase Six 10 References 12 I. Introduction Making use of the Gibbs model of reflection as a framework and guide, this paper undertakes a reflection on an incident relating to drug error or medication error in nursing practice, both from a theoretical point of view and a practical point of view. The Gibbs model of reflection divides the process into six stages, namely, the Description phase, where the event or topic is discussed; the feelings phase, where one’s thoughts and feelings about what happened are described; the Evaluation phase, where the positive and negative aspects, the pluses and minuses, good and bad aspects, of the experience or event are discussed; the Analysis phase, where one tries to piece together what the underlying dynamics and causes of the event or situation are, where one tries to grasp the essence of the event; the Conclusion phase, where one wraps up the preceding phases and tries to determine other courses of action that could have been pursued; and the Action Plan phase, where one draws up contingencies and plans of actions in the event of the reoccurrence of the incident or situation (The University of Northampton n.d.; La Trobe University 2011; Education Drop-In Centre 2012). Medication error or drug error is defined as any mistake or error in the administering a drug or medication, owing to a number of events, including mistakes in the way the drug was routed when administered, mistakes in the dosage administered, lapses in the prescription and administration of drugs for medical conditions, making use of expired medication, mistimed administration of the medication, and mistakes of ignorance arising out of not knowing what the adverse drug reactions are and what the adverse reactions are when co-administering or mixing different kinds of drugs or medications (Elsevier 2009; US Food and Drug Administration 2013; Hahn 2007; CTVNews.ca Staff 2013). The literature meanwhile traces the causes of medication errors to a number of factors, including that the handwriting in medical prescriptions are poor and its contents cannot be determined with certainty at the time of the reading; mistakes in choosing among drugs that have similar naming; and inadequate data relating to patient histories, sensitivities to certain medications, and any allergic reactions to any and all considered medications (Elsevier 2009). The emphasis in the discussions on medication errors is that they can be prevented, and the event itself has led to the misuse of medication or and the harming of the patient who took the medication. Medication error too covers the time when any and all medication is being handled not just by the medical practitioner, but also by the patient taking the medication itself, as well as the general consumer who has access to the medication. Medication error events, moreover, are tied to systems and procedures as well as the products of health care; the communication of the order; the labeling and packaging of the drug; the distributing, dispensing and compounding of a drug product; educating the patient about the drug; and the use and monitoring of the use of the drug by the patient. In all of these aspects there are possibilities for the occurrence or commission of drug error acts on the part of the involved parties, as discussed above (US Food and Drug Administration 2013). Moreover, the literature notes that there are different rates of medication errors and adverse events associated with different classes and types of drugs, with some drugs, such as insulin and morphine, associated with higher rates of medication errors in their various aspects, including in their administration and in certain high-risk contexts, such as in acute care settings. The literature notes that medication errors also have aspects that are beyond the control of the individual health care practitioners, such as nurses, as some embedded and deeply ingrained aspects of hospital procedures and systems predispose medical staff to making medication errors. Meanwhile, in terms of events, overdosing is identified as the most prevalent event related to medication errors, followed by allergic sensitivities and medication side effects. Medication errors are also more prevalent among older patients, due to the statistically larger number of prescriptions handed out to elders compared to younger patients. Dosing-related medication errors apart from overdosing include ceasing medication before the prescribed time, mistimed administration, and missed doses (Hahn 2007). II. Description of Event- Phase One The error in medication in this reflection has to do with the administration of expired medication that was checked before it went to completion. The drug in question is the insulin Humalog that was supposed to be administered on time, but which was left outside the refrigerating unit at the temperature of the room prior to its administration to the patient. A review of the literature notes that there are various issues with the handling and administration of various forms of insulin, and various packaging, with the efficacy of the vials once opened, and once left to stand at room temperature for prolonged periods of time, being compromised. That said, here the question of efficacy is tied to the expiration of the medication once it has not been handled properly, apart from the stated expiration date of the medication in the packaging. The case here is that the handling of the medication prior to administration, in sensitive medicines such as insulin, has a bearing on the efficacy of the medication and the appropriateness and accuracy of the administration of such medication. Here there is a loophole possibly that can lead to medication errors. In the case of the insulin, the reduction in the efficacy of the medication can result in adverse consequences to the diabetic patient, similar to underdosing or completely missing out on a dose, when the insulin has ceased to be potent and effective. The handling of the Humalog vials were the key issue and event that put into doubt the validity of the protocols prescribed to administer the insulin to the patient, when there was a chance that the insulin’s effectiveness had been compromised due to inadequate or poor handling. In the current case, and as the literature notes, there are variations in the amount of time that vials of insulin are left open and are left stored at room temperature within which they can be used effectively for their intended diabetic purposes. The Humalog case is four weeks of continued effectiveness once the vial is opened, and regardless of whether it is at room temperature or stored in the refrigeration unit for the medicine. For Humalog cartridges, the prescribed period of effectiveness is anywhere from seven days to 10 days. For Humulin N it is just 7 days. Novolog vials and cartridges are supposed to retain its efficacy for 28 days when stored at the temperature of the room, even as it lacks such time estimates for the case when the vials and cartridges are stored in refrigeration units (Grajower et al.2003; Drugs.com 2013). In the current case, the insulin that was used was Humalog. In this particular case, an opened vial of Humalog was considered for use, which was left out of the inventory and was included in the medicine mix to be used on the patients. The estimate by the group, in the absence of the requisite documentation, was that it had been stored at room temperature for three weeks, but there was no validating that. The absence of a proper cataloguing prevented a proper determination of times of storage and time that the vials have been left open. These Humalog stocks were considered for administration to a patient who needed the insulin. The problem was that a proper review of the literature put to doubt the efficacy of the opened vials stored in that way. Also, given that the batch of Humalog fell through the cracks, so to speak, in terms of proper documentation and processing through the procedures for medication acquisition, it is an outlier batch that could have presented problems to the patient and to the staff if administered. It is clear in this case that this is a potential scenario for a medication error, with the use of a medication that is potentially inappropriate and questionable in its efficacy due to questionable handling and lack of documentation. The ambiguity too in the literature on just how well the medication retains its efficacy when stored in varying conditions adds to the uncertainty relating to its appropriateness for use by the client (Grajower et al. 2003; Hahn 2007; US Food and Drug Administration 2013; Education Drop-In Centre 2012). III. Feelings – Phase Two My feelings included ambivalence and a certain disappointment that the medication was considered for use at all and almost slipped through the cracks to reach the patient, given the questionable background of the opened vials and the way the literature provided by the manufacturers themselves leaves the handling prone to mistakes. There was a certain level of confusion too, that something that is supposed to be very basic is not adequately addressed in the available protocols that have to do with handling insulin and properly storing the insulin prior to use. At the same time, given the amount of work that is routinely handled in the group, and given that this ambiguous way of handling insulin in the protocols have persisted for quite some time, it is understandable that unless there is more rigor and more scrutiny in the storage and handling practices for insulin and other related medication, then there will be corresponding ambiguity in the appropriateness of the medication. In cases of complications for instance that may or may not have resulted from the insulin administration to a patient, the question arises as to whether the fact that the insulin has been handled a certain way, leading to a probable nullification of its intended efficacy and the possible alteration in its effects due to being left open and at room temperature in the vial. These are complications the answers to which cannot be fully ascertained owing to the ambiguity in the way the medication is handled. All these thoughts have bred further confusion and some sense of frustration too. After the batch of medication was finally excluded from administration, there was a sense of relief, and a sense of wanting to address the loopholes that have resulted in the situation arising with the use of Humalog as it was handled and stored. These contrasting emotions, first frustration and disappointment, and second relief and the a sense of achieving clarity, point to some major discrepancies in the system that need to be rectified and clarified as far as handling insulin and related medication is concerned. This is to prevent the occurrence of medication errors as described above (Grajower et al. 2003; Hahn 2007; US Food and Drug Administration 2013; Education Drop-In Centre 2012; The University of Northampton n.d.). IV. Evaluation- Phase Three I was able to glean many telling insights into the nature of insulin storage and the way our systems and processes contain loopholes that create uncertainty and ambiguity with regard to how exactly we are supposed to be handling insulin medications like Humalog. I realized that there needs to be clarity and consistency in the way we store and procure Humalog and other types of insulin for use with our patients. By removing the ambiguities in storage and coming up with well-defined processes for handling insulin, we are saving ourselves from the uncertainties associated with improper handling. I thought this was an important insight at the time, and something that was not being addressed prior to the incident. This is an opportunity to stress test our systems and procedures and to add rigor and a certain level of confidence in the way we do things and the way especially that we handle the important medications of our patients. All this is in the name of reducing medication errors and improving the kinds of health outcomes that we are able to generate. That the opened vials of Humalog almost slipped through the procedures is a cause for concern, as well as the ambiguous prescriptions on efficacy and storage provided by the manufacturers. On hindsight I would definitely not want to experience that kind of frustration and uncertainty moving forward, especially with regard to crucial medication like Humalog and other types of (Grajower et al. 2003; Hahn 2007; US Food and Drug Administration 2013; Education Drop-In Centre 2012; The University of Northampton n.d.).. V. Analysis- Phase Four The literature tells us that some of the systemic mistakes, loopholes and errors tied to most hospital systems and processes are partly to blame for a substantial number of medication errors. This is clearly a case of the system failing to provide unambiguous guidance on how to handle and treat opened vials of insulin that were stored outside of the protocols, at room temperature rather than in the refrigeration units. It is easy to oversee, for instance, that inadequate documentation and inadequate procedures and guidance that can consistently handle insulin in all cases is the immediate cause of the confusion and the problem that could have led to medication errors. On the other hand, given that this is not the first instance of Humalog use, it can be deduced that similar errors in rigor and consistency could have occurred in the past too. The literature notes that this is a common systemic problem that leads to medication errors, as it relates to the inadequacy of guidance and communication on what to do exactly with such cases of Humalog use. Meanwhile, examining the literature on insulin handling and storage, it is clear that where medical professionals attempt to gain clarity, they encounter the same ambiguous information on just how to handle insulin when opened from their vials, stored in the refrigeration units, or exposed at room temperature for a specified period of time. This ambiguity may have contributed to the lack of standardization in our institution with regard to handling insulin prior to its administration to the patient (Grajower et al. 2003; Hahn 2007; US Food and Drug Administration 2013; Education Drop-In Centre 2012; The University of Northampton n.d.). VI. Conclusion- Phase Five There needs to be drafted a clear set of procedures for handling insulin, both when unopened and when the vials are opened, and both for room temperature and refrigeration storage modes. There needs to be more rigorous tracking too, in the system, of all medication that has been issued, the state of their use, where they are stored, date stamps for use, and tied back to data on their efficacy and discard dates. This needs to be done within the system, with the information systems for tracking the inventory also possibly addressed to accommodate these changes. The literature stresses the importance of proper documentation, and the use of robust information systems, to reduce medication and other errors (Barnsteiner 2005; Bates et al. 1999) VII. Action Plan- Phase Six This experience is an eye-opener with regard to being vigilant and being proactive in identifying weaknesses in processes and systems, and identifying potential solutions to address those shortcomings and weaknesses. In the current case, this involves clearly identifying procedures for handling insulin in different use cases and storage scenarios. This also involves looking at changing the systems to accommodate these, and to make the processes less prone to generating medication errors. I feel more confident that by being vigilant, the system and the processes will become better over time, and that our patient outcomes will continue to improve (Barnsteiner 2005; Bates et al. 1999; Grajower et al. 2003; Hahn 2007; US Food and Drug Administration 2013; Education Drop-In Centre 2012; The University of Northampton n.d.). . References Barnsteiner, Jane 2005. Medication Reconciliation. American Journal of Nursing. [Online]. Available at: http://www.wapatientsafety.org/downloads/MedReconAmJNursing2005.pdf [Accessed 7 April 2013] Bates, David et al 1999. The Impact of Computerized Physician Order Entry on Medication Error Prevention. Journal of the American Medical Informatics Association 6. [Online] Available at http://171.67.114.118/content/6/4/313.full [Accessed 7 April 2013] CTVNews.ca Staff 2013. ’This is unacceptable: cancer patient speaks out on diluted drugs. CTV News. [Online] Available at: http://www.ctvnews.ca/health/this-is-unacceptable-cancer-patient-speaks-out-on-diluted-drugs-1.1222157 [Accessed 7 April 2013] Drugs.com 2013. ’Humalog. Drugs.com. [Online] Available at: http://www.drugs.com/humalog.html [Accessed 7 April 2013] Education Drop-In Centre 2012. Gibbs’ Model of the Reflective Cycle. University of Glamorgan. [Online]. Available at: http://edic.glam.ac.uk/media/files/documents/2012-11-27/Gibbs_Model_of_the_Reflective_Cycle.pdf [Accessed 7 April 2013] Elsevier 2009. Medication Error. Mosby’s Medical Dictionary 8th Edition/ The Free Dictionary. [Online] Available at: http://medical-dictionary.thefreedictionary.com/medication+error [Accessed 7 April 2013] Grajower, Martin et al 2003. How Long Should Insulin Be Used Once a Vial Is Started? Diabetes Care 26 (9). [Online] Available at: http://care.diabetesjournals.org/content/26/9/2665.full [Accessed 7 April 2013] Hahn, Kathryn 2007. The “Top 10” Drug Errors and How to Prevent Them. Medscape Education. [Online]. Available at http://www.medscape.org/viewarticle/556487 [Accessed 7 April 2013] La Trobe University 2011. Gibbs Model of Reflection (1988). Reflective Practice in Health Sciences. [Online] Available at: http://latrobe.libguides.com/content.php?pid=177292&sid=1591490 [Accessed 7 April 2013] The University of Northampton n.d. Gibbs Reflective Cycle. NUPAD Resources for Personal Development Training. [Online] Available at: http://pdp.northampton.ac.uk/PG_Files/pg_reflect3.htm [Accessed 7 April 2013] US Food and Drug Administration 2013. Medication Errors. US Food and Drugs Administration- Drugs. [Online] Available at: http://www.fda.gov/drugs/drugsafety/medicationerrors/default.htm [Accessed 7 April 2013] Read More