Nurse Medication Error Reflection: Gibbs

Description

During a busy late shift on a surgical ward, I was preparing the evening medication round. One patient was prescribed two medicines with visually similar packaging that were stored next to each other in the treatment room. I selected the wrong box, drew up the dose, and only noticed the discrepancy during my final check against the prescription chart at the bedside. I stopped, disposed of the prepared dose, and administered the correct medicine. No incorrect medication reached the patient. I reported the near miss through our incident reporting system and informed the nurse in charge before the end of the shift.

Feelings

My immediate feeling was a jolt of alarm, followed quickly by relief that the final bedside check had caught the error. Later that evening I felt embarrassed and questioned my competence, even though nothing had reached the patient. I also noticed some reluctance to submit the incident report - a worry about how it would reflect on me - which I recognised as unhelpful and pushed through.

Evaluation

What went well is clear: the checking process worked exactly as designed. The five rights check at the bedside was the safety net that caught the slip. Reporting the near miss promptly was also the right thing to do. What went less well was that I allowed the pace of the shift to compress my preparation checks in the treatment room, and I had not consciously registered that two similar-looking products were stored adjacent to each other - a known error trap.

Analysis

Reading about medication safety afterwards, I recognised this as a classic look-alike packaging risk compounded by time pressure - a systems issue as much as an individual one. Human factors literature is consistent that busy environments increase reliance on pattern recognition, which is exactly when selection errors occur. My final check succeeded because it was a deliberate, rule-based step rather than a habit. The near miss also highlighted a storage arrangement that made an error more likely for every nurse on the ward, not just me.

Conclusion

I learned that safe administration depends on protecting each checking step even under pressure, and that near misses are valuable safety information rather than personal failings. If a similar situation arises, I will slow the preparation stage deliberately and treat any interruption as a trigger to restart my checks.

Action plan

I raised the storage issue with the ward manager, and the two products have now been separated with a shelf warning label added. I have committed to a personal rule of re-checking from the beginning whenever I am interrupted during preparation. I also plan to complete a medication safety update as part of my CPD and to share this near miss (appropriately anonymised) at our next team safety huddle so colleagues are aware of the error trap.