Reflective Essay Sample: Gibbs Cycle: Reflecting on a Near-Miss Medication Error

Model Answer

This account uses Gibbs’ (1988) six-stage Reflective Cycle to examine an incident from my second-year adult nursing placement on a busy medical ward, where a near-miss medication error was identified before it reached the patient. Gibbs’ model was chosen because its structured, sequential stages – description, feelings, evaluation, analysis, conclusion and action plan – support a disciplined move from raw recollection towards theory-informed learning, rather than a purely emotional retelling of events. The names of the patient, ward, and colleagues have been changed throughout to preserve confidentiality, in line with the Nursing and Midwifery Council (NMC, 2018) Code.

Description

During a late shift in my seventh week of placement, I was supporting my mentor with the 18:00 medication round on a six-bed bay of an acute medical ward. One patient, referred to here as Mr B, was a 74-year-old man prescribed digoxin as part of his management for atrial fibrillation. His electronic drug chart also listed a recently added instruction to withhold the next dose pending a repeat blood test, because his most recent potassium and digoxin levels had returned borderline that morning. Earlier in the shift I had read the chart quickly while preparing the trolley, and the withhold flag had not registered with me; I had mentally filed Mr B under “routine digoxin, no changes” based on the previous day’s round. I drew up the dose from the ward’s controlled stock alongside another patient’s medication and was walking towards the bay when my mentor, as she did before every high-risk drug, asked me to confirm the chart one final time at the bedside before administration. On rechecking against the live chart rather than my memory of it, I noticed the withhold instruction clearly for the first time. I stopped immediately, did not administer the dose, and reported the discrepancy to my mentor and the nurse in charge within minutes. No harm reached the patient at any point; the dose was correctly withheld, the incident was logged as a near-miss per trust policy, and the prescribing doctor was informed the same evening.

Feelings

My immediate feeling, in the seconds after I noticed the withhold instruction, was a sharp spike of anxiety, almost a jolt, followed very quickly by relief once I registered that the dose had not actually left my hand and entered the patient. I felt embarrassed that I had drawn the medication up without checking the live chart properly first, and I worried, in that moment, that my mentor would see this as evidence that I was not yet safe to be trusted with medication rounds even under supervision. There was also a flicker of defensiveness that I am not proud of, an urge to explain that the ward had been unusually busy that afternoon, before I caught myself and recognised that busyness is not a valid excuse for skipping a safety step. Underneath the embarrassment sat a quieter feeling of gratitude for the double-check culture on the ward, and for a mentor who modelled that habit consistently rather than treating it as an optional formality reserved for particularly complex patients. Later that evening, once the immediate adrenaline had faded and I had written up the incident form with my mentor, I also felt a real, if slightly surprising, sense of professional pride: the systems and habits I was being taught had worked exactly as intended, and for the first time I had been an active part of that safety net rather than simply observing someone else operate it.

Evaluation

On the positive side, the ward’s standard practice of an independent, at-the-bedside second check before any high-risk medication, including digoxin, functioned exactly as designed on this occasion. My mentor’s prompt to recheck the chart at the point of administration, rather than relying on an earlier read from an hour before, created the specific opportunity for the discrepancy to be caught before it became an actual incident rather than a near-miss. I also evaluate positively my own response once the discrepancy was identified: I stopped rather than continuing on autopilot, I did not attempt to quietly correct the situation and say nothing to avoid embarrassment, and I escalated honestly and promptly to both my mentor and the nurse in charge. What went considerably less well was my initial chart check earlier in the shift, which I now recognise was rushed because the bay was busy, I was conscious of the round falling behind, and I had unconsciously substituted memory of the previous day’s chart for a genuine, current read. This suggests that time pressure and familiarity had already begun to erode my attention to detail well before the second check intervened, which is a pattern worth taking seriously rather than dismissing as an isolated, one-off lapse specific to this single shift.

Analysis

Digoxin is a well-documented high-alert medication with a narrow therapeutic index, meaning the margin between a therapeutic dose and a toxic one is small, particularly where renal function or electrolyte balance, such as serum potassium, is compromised (Joint Formulary Committee, 2023). National guidance on medicines optimisation and incident prevention consistently identifies independent double-checking of high-risk drugs as one of the most effective defences against administration error, precisely because it does not rely on any single individual’s attention remaining perfect across a whole shift (National Patient Safety Agency, 2007; Royal College of Nursing, 2021). Reason’s (2000) Swiss Cheese Model of accident causation offers a particularly useful lens here: no single safeguard in a complex system is ever fully reliable, and serious errors typically occur only when the “holes” in successive, independent layers of defence happen to align at the same moment. In this case, my rushed and memory-reliant initial check represented one such hole, but the ward’s embedded, bedside second-check culture represented an intact subsequent layer that closed the gap before it could reach the patient.

Applying Reason’s framework, it would be both inaccurate and professionally unhelpful to frame this purely as an individual error requiring individual blame; the NMC (2018) Code and the wider patient safety literature increasingly favour a “just culture” approach, which distinguishes genuine, understandable human error from reckless or wilful practice, and treats near-misses as valuable learning data for improving systems rather than as incidents to be concealed out of fear of punishment (NHS England, 2022). At the same time, a just culture explicitly does not remove personal accountability from the individual involved. Benner’s (1984) novice-to-expert model helps explain why, as a student at a relatively early stage of clinical exposure, I was more dependent on explicit, rule-following procedures such as the full chart check than an expert nurse who might integrate contextual cues and pattern recognition more fluidly and safely; this observation reinforces, rather than excuses, the importance of following the checking procedure completely, on every single occasion, regardless of workload or apparent familiarity with a patient.

Conclusion

This incident showed me clearly that safe medication administration depends on layered, overlapping systems, not on any one person’s vigilance alone, but also that each individual layer within that system, including my own contribution, still has to be performed properly and fully for the wider system to hold under pressure. I concluded that busyness on a ward is never a legitimate reason to shorten, rush, or mentally skip a safety check, because the very moments when a ward feels most rushed are frequently the moments when errors of exactly this kind are most likely to occur. I also concluded that honest, immediate escalation is not, as I briefly feared in the moment, a sign of incompetence to be hidden; it is precisely the behaviour that patient safety systems and a just culture depend upon, and concealing a near-miss out of embarrassment would in fact have been the genuinely unsafe choice, with real consequences for future learning. Alternative actions were clearly available to me at the point of my first, rushed chart check, most obviously slowing down deliberately and treating every chart review as a fresh task rather than a formality, and I recognise this as the specific change most within my own control going forward, rather than something dependent on ward staffing or pace alone.

Action Plan

Going forward, I will treat every drug chart check as a discrete, standalone task requiring my full attention in the moment, rather than something completed automatically while mentally moving on to the next patient or task on my list, and I will say so out loud to colleagues if I feel rushed, so that time pressure becomes visible and shared rather than something absorbed silently and alone. I will continue to welcome, rather than resent or rush through, independent double-checks from mentors and registered colleagues, and once registered myself I will actively perform this role for junior colleagues and students, understanding it as a core professional duty rather than a bureaucratic courtesy that can be waived when the ward is busy. I plan to complete my trust’s e-learning module on high-alert medications this term, to discuss this incident, fully anonymised, in my next clinical supervision session, and to use it as a concrete, honest example when I come to write my end-of-placement reflective log and, eventually, revalidation-style evidence of learning from practice. Finally, I intend to read further around just-culture approaches to patient safety over the coming months, so that as a future registered nurse I can better support colleagues who disclose their own near-misses with the same honesty, and without the same fear of blame, that I tried to show here. I will also ask my mentor, at the start of each future shift, to briefly walk through any patients on the bay with recent chart changes, so that updates such as a withheld dose are flagged verbally as well as electronically, adding a further, low-cost layer of defence against the same type of error recurring.

References

• Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park: Addison-Wesley.
• Gibbs, G. (1988) Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Further Education Unit, Oxford Polytechnic.
• Joint Formulary Committee (2023) British National Formulary. 85th edn. London: BMJ Group and Pharmaceutical Press.
• National Patient Safety Agency (2007) Safety in Doses: Medication Safety Incidents in the NHS. London: NPSA.
• NHS England (2022) A Just Culture Guide. London: NHS England.
• Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
• Reason, J. (2000) ‘Human error: models and management’, BMJ, 320(7237), pp. 768–770.
• Royal College of Nursing (2021) Medicines Management: RCN Guidance for Nursing Staff. London: RCN.