NURS4172 Dimensions of Advanced Nursing

Essay 1: word count 1500

Reflection on, and analysis of, a critical incident, with reference to fundamental patterns of knowing  

1. Begin your essay with a short introduction to the themes you will be exploring, and the structure of the essay itself (approximately 150 words)
2. Identify a critical incident from your previous experience in nursing practice. Describe the incident in sufficient detail for the reader to understand the scenario, without compromising confidentiality (e.g. use a pseudonym, and do not name the hospital, ward, health center,r or unit).

You can place the scene in an appendix so it does not count within the word limit, but keep it succinct (one-page maximum).

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Solution

Introduction

Medication safety prevents patient harm with drugs use, impacts patient outcomes and the overall cost of healthcare (World Health Organization, 2019). It is the freedom of medication errors during the prescription and administration process.  A medication prescription should have the patient’s name, age, weight, and diagnosis. The medicine should have the correct dose, and strength, route of administration, time, and frequency. The instruction list should also include the storage method to maintain the drug’s effectiveness (Tariq, et al, 2020). NICU is the newborn or the neonatal intensive care unit. NICU is a nursery in a hospital with special equipment such as smart pumps to take care of sick newborns, babies who need specialized nursing care, or premature babies (Melton, et al, 2019). NICU has specially trained healthcare providers such as neonatal nurse practitioners and neonatologists to provide specialized care for newborns. Babies in NICU require complex medical interventions to improve their outcomes. NICU is a critical environment with vulnerable patients that increases the chances of medication errors that may cause adverse drug reactions such as convulsions, tachycardia, and even death. Medication safety in NICU requires a team of nurses, nurse practitioner pharmacists, respiratory therapists, and neonatologists.

Critical Incidence

Baby X.Y is a two-day-old baby weighing 1500 grams. She was born at 34 weeks via emergency caesarian section due to pre-eclampsia. She was in NICU due to apnea of prematurity, low birth weight, and prematurity. The neonatologist nurse practitioner plan of management sheet includes aminophylline, intermittent positive pressure ventilation, monitoring of the vital signs (blood pressure, temperature, and oxygen saturation), assisted feeding, and weight monitoring. The prescription booklet included the name, age, gender, weight, drug dosage, strength, frequency, and time. The prescription in the treatment sheet has aminophylline 5mg/kg IV loading dose then 3mg/kg intravenously eight hourly. The nurse administered as per the prescription, but the baby did not respond well on the first day of treatment. The nurse on duty changed to caffeine 5mg/kg once a day maintenance dose to relieve the apnea. Caffeine was effective because the baby responded quickly after the drug administration. Twenty minutes after caffeine administration, the baby presented with tonic-clonic seizures that lasted for five minutes and tachycardia. Upon neonatologist emergency review, she stated that the seizure was an effect of the sudden change of medication from aminophylline to caffeine.

Issues In The Critical Incidence

Apnea of prematurity is the cessation of breathing for more than 20seconds. It is associated with bradycardia and reduced oxygen saturation (Coughlin, et al, 2020). The causes of apnea of prematurity are upper airway instability and the obstruction of chest wall muscles. In the incidence, safe medication practices included the correct medication, prescription, and administration to improve the apnea of prematurity. The treatment plan for this patient includes aminophylline, intermittent positive pressure ventilation, monitoring of the vital signs (blood pressure, temperature, and oxygen saturation), assisted feeding, and weight monitoring. Aminophylline is the drug of choice in treating apnea of prematurity. It relaxes the smooth muscles of the respiratory tract and suppresses the response of the airway stimuli. Intermittent positive pressure ventilation helps assist the baby in breathing to improve oxygen saturation.

Prescription errors include vaguely written drug, insufficient dose or strength, no frequency, and time indicated (Atif, et al, 2018). Neonatologist nurse practitioner writes the patient’s name, age, gender, and diagnosis. In addition to that, there was a clear description of the specific drug, its dosage, strength, time of first dose administration, and frequency. This information in a prescription helps the nurse when dispensing the medicine to administer the correct drug to the right patient and administer the correct dose to ensure its effectiveness to improve patient’s outcome. However, the nurse made drug administration errors by dispensing the medicine against the prescription.

Administration error is failure to dispense drugs as per the prescription. It includes administering the wrong drug, wrong dosage, failing to match the route of administration, and intervals of the drug (Härkänen, et al, 2019). The nurse dispensed the wrong medication. She administered a caffeine maintenance dose of 5mg/kg IV that was not in the patient’s prescription sheet. She also altered the drug frequency and time of administration. Caffeine administration begins with a loading dose of 10-20mg/kg IV stat, then a maintenance dose of 5-10mg/kg once a day.

Caffeine antagonizes adenosine at its receptors and thereby stimulating the respiratory center in the medulla, increasing skeletal muscle tone, sensitivity to carbon dioxide, and diaphragm contractions. Therefore, it improves respiratory efforts in infants. Caffeine is the preferred drug of choice in the treatment of prematurity apnea because of its effectiveness in the stimulation of the respiratory system (Atik, et al, 2017). However, caffeine increases neonatal morbidity, increases the length of hospital stay, and causes toxicity at higher doses. Aminophylline is effective in treating prematurity apnea. It is available and affordable. According to Habibi, et al, (2019), aminophylline has lesser adverse effects compared to caffeine.

Carper’s Fundamental Patterns Of Knowing 

Medication safety improves the patient’s outcome and prevents harm. Healthcare practitioners maintain medication safety through medical safety ethics, law, evidence-based practices, aesthetics, and personal knowledge. Ethical principles are the moral values that guide nursing practice to do the right thing (Vaismoradi, et al, 2021). These principles are non-maleficence, beneficence, and justice. Non-maleficence means protecting the patient from harm. Beneficence means doing the right thing, and justice is being fair to all patients despite their background. These principles enhance medication safety to ensure the patient’s well-being. Medication safety laws and liabilities are the regulations followed when prescribing and administering drugs to a patient. Breach of these regulations warrants the care provider’s punishment or legal implications. Ethics, law, and liabilities enhance medication safety.

Aesthetics are the principles set in a particular work environment. In NICU, principles that would ensure medication safety are correct medicine, dosage, route of administration, frequency, and intervals. The treatment sheet should have the patient’s description to avoid confusion. Nurses should dispense medicine for one patient at a time to avoid administering the wrong medicine to the wrong patient. The pharmacist should calculate the strength of the drug prescribed to ensure its effectiveness and avoid adverse drug reactions.

Empirical information is concerned with experience. Evidence-based studies show that medication safety in NICU improves patient outcomes by giving the right treatment to the right patient, right medication, right dose, right route, right time, and right patient education. According to Wahr, et al, (2017), evidence shows that medication safety improves by having adequate staffing of nurses and pharmacists, having effective medication reconciliation strategies, implementing appropriate technology, fostering a culture of accountability that values quality improvement, and improving nurses’ workflow.

Summary

Medication safety is freedom of medication errors during medication prescription, use, and administration process. Medication safety in NICU improves patient outcomes and prevents adverse reactions. A team of nurses, nurse practitioners, neonatologists, and pharmacists help in ensuring medication safety.

References

Atif, M., Azeem, M., Sarwar, M. R., Malik, I., Ahmad, W., Hassan, F., … & Rana, M. (2018). Evaluation of prescription errors and prescribing indicators in the private practices in Bahawalpur, Pakistan. Journal of the Chinese Medical Association, 81(5), 444-449.

Atik, A., Harding, R., De Matteo, R., Kondos-Devcic, D., Cheong, J., Doyle, L.W. and Tolcos, M., 2017. Caffeine for apnea of prematurity: Effects on the developing brain. Neurotoxicology, 58, pp.94-102.

Coughlin, K., Posencheg, M., Orfe, L., Zachritz, W., Meadow, J., Yang, K. and Christ, L., 2020. Reducing variation in the management of apnea of prematurity in the intensive care nursery. Pediatrics, 145(2).

Habibi, M., Mahyar, A. and Nikdehghan, S., 2019. Effect of caffeine and aminophylline on apnea of prematurity. Iranian Journal of Neonatology IJN, 10(2), pp.37-41.

Härkänen, M., Vehviläinen-Julkunen, K., Murrells, T., Rafferty, A.M. and Franklin, B.D., 2019. Medication administration errors and mortality: incidents reported in England and Wales between 2007 ̶ 2016. Research in Social and Administrative Pharmacy, 15(7), pp.858-863.

Melton, K.R., Timmons, K., Walsh, K.E., Meinzen-Derr, J.K. and Kirkendall, E., 2019. Smart pumps improve medication safety but increase alert burden in neonatal care. BMC medical informatics and decision making, 19(1), pp.1-11.

Tariq, R. A., Vashisht, R., & Scherbak, Y. (2020). Medication errors. StatPearls [Internet].

Vaismoradi, M., Fredriksen Moe, C., Vizcaya-Moreno, M.F. and Paal, P., 2021. Administration of pro re nata medications by the nurse to incapacitated patients: An ethical perspective. Clinical Ethics, p.14777509211034146.

Wahr, J.A., Abernathy III, J.H., Lazarra, E.H., Keebler, J.R., Wall, M.H., Lynch, I., Wolfe, R. and Cooper, R.L., 2017. Medication safety in the operating room: literature and expert-based recommendations. BJA: British Journal of Anaesthesia, 118(1), pp.32-43.

World Health Organization, 2019. Medication safety in polypharmacy: technical report (No. WHO/UHC/SDS/2019.11). World Health Organization.

 

 

 

 

 

3. Use a structured model of reflection to identify the key issues associated with your critical incident scenario (approximately 500 words)

 

4. Explore these key issues with reference to Carper’s fundamental patterns of knowing (approximately 700 words)

 

5. Conclude your essay with a summary of your learning through this exercise (approximately 150 words)

 

The essay should have a formal academic structure and meet the presentation and referencing standards of the School of Health Sciences (see your Course Handbook for details).

 

 

References

 

There are many papers and books available on learning through reflection and Carper’s ‘ways of knowing’.  You should be able to identify your own resources through browsing the library shelves for nursing theory textbooks, and searching online. At Master’s level, a 1500 word written assignment should be supported by at least 10 references.