Index SituationAnalysis of the situation using knowledge methodsReflection and conclusionWorks CitedSituationMy first experience with a medication error occurred at the beginning of my nursing profession. It was during a case of lysis due to deep vein thrombosis of the lower extremities. In these cases we insert a catheter into the femoral artery and drip heparin and tissue plasminogen activator (tPA) near the site of the clot for at least five hours. Once staff hear the word tPA, it causes great compulsion and they know they will be dealing with a long case. This procedure is very complex, stressful and time consuming as staff have to come in several times during the night to check how the clot is reacting. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get an Original Essay While my preceptor and I were preparing the initial IVs, pumps, medications, and protocols for the procedure, I went to get the heparin from the medication dispenser. I went to the system and typed in the correct medication and concentration. The drawer opened to allow me to take the medicine. I showed it to my preceptor and she confirmed that it was the right concentration. We then stopped the medications and transferred the patient to the intensive care unit for observation until we returned later that evening. Upon returning, the nurse caring for our patient asked us if we had checked the medication because it was not the concentration of medication listed in the protocol. They were right, it wasn't the right concentration. It was actually less than what was supposed to be infused. Fortunately, they had exchanged the bag and the patient had not suffered any harm. As I went over all this in my head, I tried to understand what had happened. After some investigations we discovered that the pharmacy kept multiple concentrations of intravenous heparin in the same drawer. We met with the facility's security team and they understood that this was a hospital-wide issue. After this event they ended up not keeping the heparin in the same drawers and moved the different concentrations to different distribution units throughout the hospital. Situation analysis using knowledge methods With medication errors nurses must be resilient to be able to work and learn from their mistakes. According to Polk (1997), consistent recognition of a situation could enhance movement toward health by providing a structure for exploring the meaning of an experience. Using resilience as a nurse is essential in using “ways of knowing”. Resilience involves empirical, ethical, aesthetic, personal aspects and experiences in the nursing field in the management of medication errors. I was able to use empirical experience to understand that a certain concentration of heparin must be used for it to be effective in lysing the clot. In Zander (2007), empiricism is defined as the use of nursing science, objectively and verified through repeated testing over time. The rate of infusion of heparin at a certain concentration has been clinically verified as to what is the effective dosage to help lyse a clot. If the nurse caring for the patient had not noticed the medication error, the clot would not have been affected and the patient would not have had an ideal outcome. Ethically, I do not believe that my ethical limits or principles have been exceeded; furthermore, no one was injured. However, I felt ethically responsible for my mistake because I did not correctly use the "five rights" ofadministration of drugs. Zander (2007), states that ethical knowledge is implied as an individual's values ​​and critical consideration of what is valued as an individual's moral fiber, motivations and goals. Morally, I have not intentionally gone through any choices that have affected my values ​​or beliefs. However, this situation has made me more aware of moral issues and choices as I continue my practice as an advanced practice nurse. Since I was very green nurse, I could not provide aesthetic knowledge because I had no previous experience with this type of procedure. Zander (2007), aesthetic knowledge can be incorporated into practices associated with nursing. In this situation, I was unfamiliar with this procedure and leaned on my preceptor for guidance to ensure I was doing the right thing and that the medications were correct. Even though my preceptor was an “experienced” nurse, I should have double-checked the protocol and made sure I was hanging the right meds, instead of taking someone else's word for it. I am now fully responsible for my business and will double and triple check just to make sure a medication error like this doesn't happen again. Personally, this case has put me to the test and will accompany me throughout my nursing profession. I will always validate and verify medications and correctly use the "five rights" in my advanced practice. I am more aware of my “self” and the flaws it may contain. According to Zander (2007), personal knowledge is an individual's understanding rather than a personal way of perception. I learned a lot from this experience. It will also be a constant reminder for me to grow and develop as an experienced nurse and to always remember the "five rights" and to always check and double check when administering medications. Zander (2007) associates nursing experience as knowledge through frequent exposure. Since this was a new procedure for me, I could not reflect on my experience. However, I will continue to gain more experience through my nursing practice and by attending specialty courses so that medication errors are less frequent. I know that I am human and that mistakes may happen, but using the “ways of knowing” will provide a better way to overcome my mistakes into a more mindful and positive experience, thus benefiting my patients and my practice. Reflection and Conclusion Medication errors occur in the nursing profession and there is no way around them. A person can count, validate, and verify medications, but human errors occur. Reflecting on this I realized that the patient had not been harmed and that we were able to solve a problem that affected the entire hospital. Confirmation that I had changed something that affected the entire facility gave me the feeling that I hadn't done anything harmful to the patient and I was grateful that another nurse was there behind me to check my work. Please note: this is just an example. Get a custom paper now from our expert writers. Get a Custom Essay In Grissinger (2007), they state that rights should be used as goals and that to achieve these goals, strong support staff should be in place to encourage safe practices. I strongly agree with this statement in my medication error because without the support of the other nurses and administration this medication error could have gone very differently. However, we were able to change the hospital's practices to prevent this from happening to another patient simply by moving several!, 15(6),/9789241511643