[Reflective Account of Patient Safety]

By

ACKNOWLEDGEMENT

I am most thankful to my family colleagues and instructor for providing me assistance and guidance throughout the tenure of this research project. This research would not have been completed without their undue support.

DECLARATION

I declare that this study has not been published previously and represents my own work based on the secondary and the primary research analysis.

ABSTRACT

The purpose of this paper was to provide a reflective account of the medical error incident that occurred at my department. The reflection was based on the patient safety concern, the scholarly review of the issue and how my experience can be replicated to avoid the similar future incidents. Mostly, the patients in the Middle East countries have the same, last, middle and the first name that can endanger their treatment procedure if the healthcare workers show ignorance. The same had happened in my department where a wrong surgery was conducted to the wrong patient. Based on the Gibb's analysis of this situation it can be said that the personal reflection not only helps in improving the personal future professional experience but also help others in looking into the professional issues more closely. This is what this reflection aimed to achieve.

Table of Contents

ACKNOWLEDGEMENT2

DECLARATION3

ABSTRACT4

CHAPTER 1: INTRODUCTION7

1.1 Background7

1.2 Brief Overview of the Critical Incident7

1.3 Reflective Model Applicable to the Incident8

1.4 Background to the reflective research problem8

1.5 Aim of the Research9

1.6 Scope and Significance10

1.7 My Personal Theory10

CHAPTER 2: REFLECTIVE PRACTICE THEORY12

2.1 Experiential Learning12

2.2 Application13

CHAPTER 3: LITERATURE ON PATIENT SAFETY15

3.1 Medical Errors: A review of Middle East15

3.2 Intersections between Sociology and Organizational Studies16

3.3 Sociological Examinations of Systems Thinking and Safety Culture21

3.4 The Current Practice of Patient Protection24

CHAPTER 4: THE NATURE OF REFLECTION28

4.1 Definitions of reflection28

4.1.1 The Philosophical Meaning28

4.1.2 Reflection as a Process of Critical Self-Evaluation28

4.2 Key Theories of Reflection29

4.3 Reflective Models30

4.3.1 Kolb and Fry's (1975)30

4.3.2 Jarvis (1992)31

4.3.3 John (2000)32

4.3.4 Gibb's Model of Reflection (1988)32

4.3.5 Taylor (2004)33

CHAPTER 5:- REFLECTIVE INCIDENT- APPLIED REFLECTION35

5.1 Application of Gibb's Analysis to the Incident35

5.1.1 Description35

5.1.2 Feelings35

5.1.3 Evaluation36

5.1.4 Analysis36

5.1.5 Conclusion36

5.1.6 Action Plan37

5.2 Implementation of the JCIA Patient Safety Goals for Avoiding Future Medical Errors37

5.2.1 Goal 1: Correct Identification of the Patient37

5.2.2 Goal 2: Improve the effectiveness of communication38

5.2.3 Goal 3: Improve the safety of high-risk medications38

5.2.4 Goal 4: Ensure the correct patient is in the surgery receiving a correct a procedure38

5.2.5 Goal 5: Reducing the risk of healthcare associated infections39

5.2.6 Goal 6: Reducing the risk of patient injury due to falling39

5.3 Importance of Goal 1, 2 and 4 to the Incident40

5.3.1 Goal 140

5.3.1.1 Measurable Objective41

5.3.2 Goal 2: Improving the Effectiveness of Communication41

5.3.2.1 Requirement of Objective 241

5.3.2.2 Intent of the Objective 241

5.3.2.3 Measurable Objectives42

5.3.3 Goal 4 Ensuring Correct Surgery in Patient with Correct Procedure42

5.3.3.1 Requirement of the Objective42

5.3.3.2 Intent of the Objective43

5.3.3.3Measurable Objective43

CHAPTER 6:- CONCLUSION AND IMPLICATION FOR PRACTICE45

6.1 Implication for a Practitioner45

6.2 Implication for Organization45

6.3 Implication at the Level of Policy46

6.4 Future Research46

6.5 Conclusion48

REFERENCES49

CHAPTER 1: INTRODUCTION

1.1 Background

I have been working as a staff nurse for 16 years since 1997. For the first 9 years, I worked with the ministry of ...