Explain Reflection on Medication Error Using Gibbs Cycle

Healthcare is a career that requires its specialists to have no other moral or ethical deviations possible. Even what appears to be a small mistake may be disastrous and even deadly to patients. This case study explores a life-threatening error that occurred during medication administration to a patient identified as Ruth Stoll and applies the shared somatic situational reflection on medication error using gibbs cycle, an in-depth look at the incident, factors associated with the error, and how the implications remain significant to the nursing practice. Let’s explore further with medication error reflection examples, and should you need expert help with an assignment, you can rely on Locus Assignments, one of the most reliable and trusted assignment helpers UK.

Reflection on Medication Error Using Gibbs Cycle: The Case of Ruth Stoll

Although there are many reflective models for nursing, including Gibbs' Reflective Cycle, Schön's Model (Reflection-in-action & on-action), Johns Model, and Kolb's Experiential Cycle (Concrete Experience, Reflective Observation, Abstract Conceptualization, Active Experimentation), we are going to look at this case through the lens of Gibbs’. Before diving into the drug error reflection case study, it is important to revisit the key stages of the Gibbs’ Reflective Cycle, namely: Description, Feelings, Evaluation, Analysis, Conclusion, and Action Plan. Now let’s apply the same in the form of a medication error reflection essay.

1. Description

This nurse medication error reflection example presents a situation where a 71-year-old patient, Ruth Stoll, goes to Clinpath Laboratories to have a blood test, which is a normal preoperative procedure before her cardiac surgery to determine whether she is going to require transfusion. She was sharing a room with another patient, Martha Kovendy, who was unaware of her presence. The fact was that the attending nurse made a critical mistake, which caused the mislabeling of their blood samples. A few days later, when Ms Stoll needed a transfusion, she unfortunately got the incorrect blood as a result of this confusion and passed away six days later.

2. Feelings

When I got to know about this incident, I was in deep astonishment and shock. I was horrified to see how irresponsible and seemingly heartless this nurse could have been to make such a nightmare mistake. In addition to the anger and disbelief, I also felt such considerable sadness and grief that I share the experience of loss that the family of Ms Stoll had to endure because of an easily avoidable error.

3. Evaluation

The additional assessment of this case reveals the extreme insufficiency of the appropriate surveillance and awareness in terms of collecting blood samples and further recording them. The fact that there was no follow-up or review of the blood samples and records by a senior registered nurse, which is a major prerequisite for safe and effective care delivery.

4. Analysis

In the analysis, the root cause of death is negligence. The mislabelling of the test tubes by the nurse of the two patients resulted in a series of causes and ended in the administration of incompatible blood to Ms Stoll. The case in point triggered the coroner to suggest that a member of the family or close ones should be present when the cardiac patient is going to receive care to ensure the communication is easier and that no such case of a mistake or confusion will occur again (Novis et al., 2017).

The lesson behind this incident is the fact that professional accountability and adherence to the national standards of safety practices should be the key priority that will allow nurses to provide safe and quality care. In this particular instance, the issue of accountability and responsibility with regard to her conduct in making sure that the patient was safe and secure seemed to be massively compromised, as evident in the case. To fledgling nurses, this case is a reminder of the importance of paying strict attention to safety standards in the country and guidelines in nursing practices. This kind of adherence is critical towards practising safely and effectively, such that the patient gets accurate care in an appropriate manner. The casual attitude and negligence towards her professional duties were the main pathways to this tragedy that could have been easily prevented by the nurse.

5. Conclusion

This case is an eye-opener on the real picture of the situation regarding medication errors. Medication errors are some of the greatest problems that have suppressed growth in the healthcare sector. They are frequently a direct consequence of high negligence and the absence of responsibility in the healthcare workforce, and the patients end up being the greatest casualties.

The two ethical principles of beneficence and non-maleficence require the medical worker to not engage in any action that may directly cause harm to the patient (Scott et al., 2014). In the case of Ms Stoll, however, the lab nurse, whether out of negligence or in a hurry, engaged in a practice that not only resulted in harm but has very directly killed a patient. This mistake would have probably been caught and eliminated by a registered nursing supervisor, hence the death effects being avoided. Likewise, consultation with the family members would have assisted the process of avoiding the mislabeling (Wachter et al., 2013). Thus, this accident highlights how such values of a nurse as accountability and proper compliance with safety precautions are crucial to avoid medication errors. It urges the nurses to be ever more responsible at each and every step of the medication administration process.

6. Action Plan

Based on the critical medication error reflection essay, my plan of action involves a comprehensive analysis of the reasons behind medication errors and the active learning of the ways to reduce this risk in future practice. One of the main flaws was a refusal among the lab personnel to identify patients and document specifications of their cases when taking the blood sample. So, the short-term action plan is the necessity to learn effective documentation practices since the identification of a patient and thorough documentation are the key preconditions of nursing practice.

Also, the fact that the nurse has utterly failed to make a connection with the patient and her family is a serious issue that should be addressed. My further action will be to conduct more research and become thoroughly familiar with other practice guidelines and safety models. This thorough knowledge will ensure that I am involved in safe and effective practice. In addition to this, I will promise to practise reflectively and learn from every patient experience I have so that I may improve continuously and be able to provide safe and effective care every time.

Conclusion

The Gibbs Reflective Cycle is one way in which nurses can examine and draw lessons from events like medication errors through the application of an organised framework to accomplish it. The above-mentioned nurse medication error reflection example dives into certain steps, such as description, feelings, evaluation, analysis, and conclusion, along with the action plan, allowing nurses to have a clearer picture of what has happened, why that has happened, and how to avoid such mishaps in the future. By employing different reflection models, clinical judgment is improved, patient safety is enhanced, and professional development is made stronger. With reflection on medication error using Gibbs Cycle, therapy reflection on a medication error cannot only facilitate responsibility but also lead to a lifelong educational process within the nursing practice.

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FAQs

1. How to write a reflection on a medication error?

To write a reflection on a medication error, clearly describe what happened, your role in the incident, and the outcome. Using a recognised reflective model, reflect on your thoughts and feelings, analyse why the error occurred, identify what you learned, and explain how your practice will change to prevent similar errors. 

2. What are medication error reflection examples in nursing? 

Examples of reflection in nursing include analysing a situation where a nurse administered medication late due to poor time management, recognising the impact on patient care, and identifying strategies such as better prioritisation and clearer communication to improve future practice.

3. What is a practical example of a medication error?

A practical example of a medication error is administering the wrong dosage of a drug due to misreading a prescription or confusing similar-looking medication packaging. For instance, giving 50 mg instead of 5 mg because the decimal point was overlooked.

4. How do you write a reflection using the Gibbs model?

To use the Gibbs Reflective Cycle, structure your reflection into six stages:

1. Description – what happened

2. Feelings – what you were thinking and feeling

3. Evaluation – what went well or badly

4. Analysis – why it happened

5. Conclusion – what you learned

6. Action Plan – how you will prevent it in the future

This approach ensures depth, clarity, and critical thinking.

5. What is the conclusion of medication error?

The conclusion of a medication error reflection emphasises the importance of patient safety, accountability, and continuous learning. It highlights how recognising errors, reflecting on their causes, and implementing preventative strategies can improve clinical practice and reduce future risks.

About the Author

Dr. Hannah Collins is a UK-based healthcare academic with experience in nursing studies and patient-centred practice. With postgraduate training in health and social care, she works with Locus Assignments to support students in analysing care and reflective models, applying theory to practice, and meeting UK academic standards in healthcare-related assignments