Introduction Of NURY3102 A Drug Error Assignment

Critical incidents in healthcare, such as medication errors, can compromise patient safety and erode trust between patients and healthcare professionals. This presentation examines an administrational medication error that occurred in a rehabilitation ward. During a night shift, a nurse administered 1000 mg of paracetamol but failed to document the administration or communicate this information during handover to the GP and morning shift nurse. As a result, the patient was at risk of receiving a double dose.

This incident highlights how ineffective communication and documentation can negatively impact patient safety. Proper information transfer during handover is essential to prevent duplication of medication and adverse drug events. The scenario also underscores the importance of leadership in managing critical incidents—ensuring errors are addressed promptly, investigated thoroughly, and used as learning opportunities without punitive consequences.

Effective leadership supports the implementation of evidence-based strategies such as standardised handover protocols, staff education, and monitoring systems to improve medication safety (Wong et al., 2019). Leaders also foster reflective practices, debriefing sessions, and a culture of psychological safety that encourages reporting and learning from errors.

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Contemporary Leadership Theories and Models

Overview of Leadership in Medication Safety

The incident demonstrates the pivotal role leadership plays in reducing medication errors and promoting a culture of safety. Analysing the event through transformational, situational, and servant leadership theories provides insight into how leadership approaches can improve communication, accountability, and patient outcomes.

Transformational Leadership

Transformational leadership focuses on inspiring and motivating healthcare professionals to achieve high standards of care and embrace continuous improvement (Broome, 2024).

Key Characteristics

• Vision and Inspiration: Establishing a shared vision for patient safety and quality care.
• Empowerment and Support: Providing resources, autonomy, and encouragement to staff (Collins et al., 2020).
• Communication and Collaboration: Promoting open dialogue and teamwork.
• Positive Work Environment: Supporting staff wellbeing, job satisfaction, and retention.
• Personal and Professional Development: Encouraging lifelong learning and skill development.

Application to the Case

A transformational leader would reinforce the importance of accurate documentation and effective handover communication. By promoting accountability and continuous learning, such a leader can reduce medication errors and encourage nurses to report mistakes without fear of punishment.

Situational Leadership

Situational leadership is a flexible approach where leaders adapt their style based on staff competence and situational demands (Alsaqqa, 2020).

Key Features

• Adaptability: Adjusting leadership behaviour to meet situational needs.
• Four Leadership Styles: Telling, selling, participating, and delegating.
• Focus on Team Needs: Providing appropriate guidance and supervision.

Application to the Case

A situational leader would recognise challenges associated with night shifts, such as fatigue and staffing pressures. Directive leadership may be used for inexperienced staff, while experienced nurses may benefit from collaborative problem-solving to address system gaps contributing to medication errors.

Servant Leadership

Servant leadership prioritises the needs of patients and staff by fostering empathy, trust, and collaboration (Trastek et al., 2014).

Key Characteristics

• Empathy and Compassion: Understanding staff challenges and patient needs.
• Collaboration and Teamwork: Encouraging shared responsibility and communication.
• Ethical Decision-Making: Upholding professional integrity and patient safety.

Application to the Case

A servant leader would promote a non-punitive reporting culture, support the nurse involved, and collaboratively address root causes such as workload or system inefficiencies (Demeke et al., 2024).

Critical Appraisal of Leadership Models

Each leadership model contributes uniquely to resolving and preventing medication errors:

• Transformational leadership promotes accountability, transparency, and motivation.
• Situational leadership ensures adaptability to staff competence and clinical context.
• Servant leadership builds trust, psychological safety, and collaboration.

Integrating these approaches creates a comprehensive framework that addresses system failures, supports staff, and prioritises patient safety.

Role of the Nurse in Delivering Patient-Focused Outcomes

Nurses play a vital role in ensuring patient-centred care through safety, communication, and accountability (Feo & Kitson, 2016).

Key Responsibilities

• Conducting risk assessments and medication safety audits.
• Using standardised handover tools such as SBAR.
• Adhering to quality standards and clinical guidelines.
• Utilising audit data to identify and address safety gaps.

Relevant NICE Guidelines

• NG5: Medication Optimisation (2015): Emphasises accurate documentation and communication during care transitions.
• NG67: Managing Medicines in Social Care (2017): Highlights staff competency, training, and communication in medication management.

Failure to document medication administration placed the patient at risk of double dosing. Implementing structured assessments and quality standards can prevent recurrence and improve patient outcomes.

Risk Assessment

Nurse as Leader, Role Model, and Change Agent

Following the incident, the nurse demonstrated leadership by acknowledging the error, escalating concerns, and participating in a team debrief. This behaviour reflected accountability, transparency, and commitment to patient safety (Fracica & Fracica, 2021).

By encouraging learning rather than blame, the nurse acted as a change agent—advocating for improved documentation practices, training, and system review to prevent future errors.

Importance of Teamwork

Effective teamwork is essential for medication safety.

Key Elements

• Delegation: Assigning tasks according to competence.
• Supervision: Ensuring adherence to protocols.
• Interprofessional Collaboration: Enhancing communication between nurses, doctors, GPs, and IT teams.

Strong teamwork promotes continuity of care, reduces errors, and enhances patient safety.

Conclusion and Reflection

This case highlights the critical role of leadership in preventing medication errors. Transformational, situational, and servant leadership models collectively promote accountability, adaptability, staff empowerment, and patient safety. Nurses act as leaders and change agents by demonstrating professionalism, learning from errors, and fostering teamwork. Effective leadership and collaboration are essential to creating a culture of safety, continuous improvement, and high-quality patient care.

References

• Alsaqqa, H. H. (2020). The Situational Leadership for the Three Realities at Healthcare Organizations. Journal of Health Systems and Policies, 2(2), 230-247.https://dergipark.org.tr/en/pub/jhesp/issue/54975/735151
• Baichoo, K., Little, H., Ragan, P., Schneller, K., & Taylor, J. (2024). Quality and Safety in the Community. A Clinician's Survival Guide to District Nursing, 211. https://books.google.co.in/books?hl=en&lr=&id=r1YmEQAAQBAJ&oi=fnd&pg=PA211&dq=B.%09NICE+guideline+NG67:+managing+the+medication+for+adults+receiving+social+care+in+the+community+(2017&ots=GFkUeEvTDb&sig=EyQnLfTCsj-Ho7BvF6Ojz8sSSOI&redir_esc=y#v=onepage&q&f=false
• Bengtsson, M., Ekedahl, A. B. I., & Sjöström, K. (2021). Errors linked to medication management in nursing homes: an interview study. BMC nursing, 20(1), 69.https://link.springer.com/article/10.1186/s12912-021-00587-2
• Broome, M. E. (2024). Transformational leadership in nursing: From expert clinician to influential leader. springer publishing company.https://books.google.com/books?hl=en&lr=&id=DyQaEQAAQBAJ&oi=fnd&pg=PR7&dq=transformational+leadership+in+healthcare+can+be+defined+as+a+leadership+approach+that+focuses+on+inspiring+and+motivating+the+healthcare+teams+to+achieve+exceptional+outcomes+and+embrace+positive+changes.+&ots=f9V5cFPbKP&sig=O1xKeAijSaZHuuWx_r8Sbebe0mM
• c). Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care–a narrative review. Safety in Health, 4(1), 1-9.https://link.springer.com/article/10.1186/s40886-018-0073-1
• Chandler, K. L. (2023). Implementation of a Situation, Background, Assessment, Recommendation (SBAR) Patient Handoff Tool in the Electronic Medical Record (EMR) (Doctoral dissertation, University of Missouri-Saint Louis).https://search.proquest.com/openview/f4e6b0b902060113877921952ac46682/1?pq-origsite=gscholar&cbl=18750&diss=y
• Collins, E., Owen, P., Digan, J., & Dunn, F. (2020). Applying transformational leadership in nursing practice. Nurs Stand, 35(5), 59-66.https://search.proquest.com/openview/ea0c079e331297eaaafe75dbdb74e304/1?pq-origsite=gscholar&cbl=2042228
• Cortes, M. (2023). The Employees’ Perspective: Situational Leadership Style Flexibility and Effectiveness and Employee Performance in a Technological Organization (Doctoral dissertation, Walden University).https://search.proquest.com/openview/d1ad6c7d3c8616287db0999022a37945/1?pq-origsite=gscholar&cbl=18750&diss=y
• Demeke, G. W., van Engen, M. L., & Markos, S. (2024). Servant leadership in the healthcare literature: a systematic review. Journal of healthcare leadership, 1-14.https://www.tandfonline.com/doi/abs/10.2147/JHL.S440160
• Feo, R., & Kitson, A. (2016). Promoting patient-centred fundamental care in acute healthcare systems. International journal of nursing studies, 57, 1-11.https://www.sciencedirect.com/science/article/pii/S0020748916000079
• Fracica, P. J., & Fracica, E. A. (2021). Patient safety. Medical Quality Management: Theory and Practice, 53-90.https://link.springer.com/chapter/10.1007/978-3-030-48080-6_4
• Ghezaywi, Z., Alali, H., Kazzaz, Y., Ling, C. M., Esabia, J., Murabi, I., ... & Antar, M. (2024). Targeting zero medication administration errors in the pediatric intensive care unit: A Quality Improvement project. Intensive and Critical Care Nursing, 81, 103595.https://www.sciencedirect.com/science/article/pii/S0964339723002136
• Goedecke, T., Ord, K., Newbould, V., Brosch, S., & Arlett, P. (2016). Medication errors: new EU good practice guide on risk minimisation and error prevention. Drug safety, 39, 491-500.https://link.springer.com/article/10.1007/s40264-016-0410-4
• Jardien‐Baboo, S., van Rooyen, D., Ricks, E. J., Jordan, P. J., & ten Ham‐Baloyi, W. (2021). Integrative literature review of evidence‐based patient‐centred care guidelines. Journal of Advanced Nursing, 77(5), 2155-2165.https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.14716
• Khan, A., & Tidman, M. M. (2022). Causes of medication error in nursing. Jour Med Resh and Health Sci, 5(1), 1753-1764.https://jmrhs.info/index.php/jmrhs/article/view/511
• Patrician, P. A., Campbell, C. M., Javed, M., Williams, K. M., Foots, L., Hamilton, W. M., ... & Swiger, P. A. (2024). Quality and safety in nursing: recommendations from a systematic review. The Journal for Healthcare Quality (JHQ), 46(4), 203-219.https://journals.lww.com/jhqonline/fulltext/2024/08000/quality_and_safety_in_nursing__recommendations.2.aspx?context=featuredarticles&collectionid=1
• Trastek, V. F., Hamilton, N. W., & Niles, E. E. (2014, March). Leadership models in health care—a case for servant leadership. In Mayo Clinic Proceedings (Vol. 89, No. 3, pp. 374-381). Elsevier.https://www.sciencedirect.com/science/article/pii/S0025619613008896
• UK, N. G. C. (2016). Medication management. In Physical Health of People in Prison: Assessment, Diagnosis and Management of Physical Health Problems. National Institute for Health and Care Excellence (NICE)..https://www.ncbi.nlm.nih.gov/books/NBK401645/
• Wong, X., Tung, Y. J., Peck, S. Y., & Goh, M. L. (2019). Clinical nursing handovers for continuity of safe patient care in adult surgical wards: a best practice implementation project. JBI Evidence Synthesis, 17(5), 1003-1015.https://journals.lww.com/jbisrir/fulltext/2019/05000/Clinical_nursing_handovers_for_continuity_of_safe.13.aspx
• Ylänne, V., Aldridge-Waddon, M., Spilioti, T., & Bartlett, T. (2021). Managing information, interaction and team building in nurse shift-change handovers: a case study. Journal of Applied Linguistics and Professional Practice, 16(1), 51-75.https://eprints.gla.ac.uk/240261/