Case Study and Reflection on Practice and Learning


Medical errors threaten public health and are a primary cause of death worldwide. It’s tough to establish a recurrent source of mistakes and much harder to provide a fix that minimizes the error’s probability. If adverse events are recognized, lessons are learned from them, and attempt to prevent future occurrences; patient safety may be improved (Hollnagel et al., 2015).

Ann gives Bob the wrong medication during a busy night shift in this Study Case. She had worked extra shifts to cover for ailing nurses. Ann typically arrives for her job exhausted since she also cares for her disabled kid and mother at home. Because of the following facts, Ann must tell Bob about her error in dispensing his medication for this case study:

According to The International Council of Nurses (ICN) Code of Morality for Nurses, Ann has to inform Bob about the medication mix-up. The code is an assertion of the ethical principles, responsibilities, and professional responsibilities of clinical nurses. The code also defines and instructs ethical clinical practice within the various roles nurses take on (Stievano &Tschudin, 2019).

A nurse’s role is to provide informed consent for healthcare and associated treatment by ensuring that the client and family get information that is culturally, linguistically, cognitively, physically, and psychologically appropriate and presented in a timely way. All members of society, including nurses, are responsible for taking the initiative to address people’s health and social needs. Although Ann was supposed to look out for Bob’s health and social needs, she made a mistake. Upon realizing, Ann checked Bob’s medical report, and found nothing had changed for him.


When weighing the pros and cons of medical interventions, bioethicists often turn to the four tenets of health care ethics (Baksheev et al., 2018). To be truly “ethical,” a medical practice must adhere to all four principles: autonomy, fairness, beneficence, and non-maleficence (Arras, 2017).

Autonomy – Patients must have authority over their brains and bodies to achieve this criterion. Decision-making cannot be manipulated. Before choosing surgery, the patient must know all possible outcomes, side effects, and benefits. Complexity and strong emotions may prevent patients from giving informed consent for ARTs. So, in our scenario, Ann should notify Bob about the error and soothe him.

Justice – Everyone should share the risks and advantages of exploring new treatments. All procedures must be legal and fair to all stakeholders. When considering justice, a healthcare practitioner must consider the equitable distribution of limited resources, competing needs, rights, and obligations, and potential legal issues. Reproductive technologies present moral problems since not everyone has equal care. Our study reveals Bob should know about the medication mix-up.

Beneficence – Mandates that the provider has positive intentions for the patient. Medical professionals must keep their knowledge and abilities current, engage in ongoing education, consider each patient’s unique needs, and work for the greatest possible positive outcome. In our case study, this medical principle was put into practice when Ann assessed Bob’s condition after making a mistake.

Non-maleficence – A procedure must be both patients- and population-safe. Infertility advocates believe they are helping humanity and creating as little harm as possible. Low success rates and unclear long-term effects of ART may harm a patient’s mental health. In some instances, doctors may struggle to practice “not harm.” Ann followed this philosophy since Bob was OK despite the medical error.

Bob should be informed of the medication mix-up for several reasons. The first step in providing him with the best care possible is to keep him updated on his condition and treatment (Ginter et al., 2018). Second, he and the nurses will develop a more vital trust by letting Bob know about the mix-up. Finally, Bob will be more conscientious about double-checking his pills in light of this error (McDonald, & Then, 2019).

Bob is a patient with a high propensity for anxiety and was previously given the incorrect medication for his condition. The medicine seemed to have no adverse effects on him at the time. However, when he found out about the error, he got so angry that he planned to sue the RN responsible.

Understandably, Bob felt upset after learning of the error in his prescription. Furthermore, his decision to file litigation against the RN who made a mistake is equally justified. It must be stressed that Ann quickly checked Bob’s medical records after recognizing her error and was confident that Bob would not be harmed. Bob is getting excellent care and attention from the nursing team, so it’s unlikely he will suffer any damage due to the mix-up.

By letting Bob know about her mistake, she will not only assist in guaranteeing that he gets the highest possible level of care, but she will also help establish trust with him and the nurses. Telling him seems to be a component that motivates the practitioner to promote patient-centered care, which is relevant when considering the nature of the connection between Bob and Ann (Horner et al., 2017). This aspect of the link has a direct bearing on the perceived value of delivered care and is essential to the success of the nursing profession.

It is essential that Bob is kept apprised of his diagnosis and services and that he is aware that the nursing team is concerned about his overall health and well-being (Wyder et al., 2015). The fact that Bob is aware of the inaccuracy will make him more careful in the future when confirming that his prescription is correct.

Lesson Learned

According to the case study, I learned that any medical practitioner could make a mistake in administering treatment. Still, they should check the patient’s medical history meticulously before that happens. Ann has to consider issuing the medications to Bob by checking his medical history to avoid mistakes. I also understand that in Nursing, we have to make choices in medical care about the rights we possess and what duties we owe to the patients (Egener et al., 2017). This law and legal issues in the health care sector are always governed by the regulations that should protect individuals when making any decisions.

What I will do if I’m in a similar situation in the future

If I encountered the same scenario in the future, I would consider explaining to the patient the mistake I made since every patient has the right to informed consent before treatment. I know the patient can be agitated because of the errors made, but my responsibility is to counsel and calm them down (Egener et al., 2017). The patient’s safety and prevention of any injury to them should always be considered, and the health care providers should prioritize these rights.

Steps were taken to build knowledge and skills

Nevertheless, there are specific steps that I can take to build my knowledge and skills in ethics, laws and health care. The first step is to learn more about the rules and ethics of health care to increase my understanding of health care services. In my perspective, learning is a process that never ends, which means that to be more knowledgeable, one must practice the aspect of learning (Gupta, 2018). Ethics and laws on health care keep changing day in and day out, and this means that I have to continue learning to be more knowledgeable next step is to improve my ethical performance to develop a code and make honest performance a priority when dealing with my patients.

Another way for me to sharpen my skills and knowledge of the laws and ethics of health care is by tuning into medical podcasts or channels that sensitize more about the rights of patients and the laws that govern them. It will be the best way to avoid making errors in my field of professionalism. Following new health care blogs will also equip me with many skills and information on the health care department (Gupta, 2018). By this, I will be able to formalize my commitment to health care goals, such as health care coverage, to achieve the best in my profession, such as how I relate to my patients and serve them.

In addition, I also have to engage my patients and always create a rapport when dealing with them. In my opinion, this includes enquiring more about their medical history to avoid making medical errors in medication. I know this will be the best form of informed consent since, by doing this, I will inform my patients about what mode of treatment I am administering (Olejarczyk & Young, 2019). To add to the steps I can take in building my knowledge and skills in laws and ethics in health care, and I will consider measuring my effectiveness in my ethics programme by asking my patients how good my services are.



In conclusion, all the ethical codes of health care should always be considered when providing medical services to any patient. Basic principles such as health maximization, non-maleficence, autonomy, justice, and beneficence should be observed when rendering services. All patients receiving medical assistance should be treated with utmost care and respect while following the laws that govern their rights as patients.




Arras, J. D. (2017). Getting down to cases: The revival of casuistry in bioethics. Ethics and Medical Decision-Making, 463-485.

Baksheev, A. I., Nozdrin, D. A., Turchina, Z. E., Sharova, O. Y., Rakhinskiy, D. V., & Yurchuk, G. V. (2018). Bioethical principles and mechanisms for regulation of biomedical research. Journal of pharmaceutical sciences and research10(4), 889-892.

Egener, B. E., Mason, D. J., McDonald, W. J., Okun, S., Gaines, M. E., Fleming, D. A., Rosof, B. M., Gullen, D., & Andresen, M.-L. (2017). The Charter on Professionalism for Health Care Organizations. Academic Medicine, 92(8), 1091–1099.

Ginter, P. M., Duncan, W. J., & Swayne, L. E. (2018). The strategic management of health care organizations. John Wiley & Sons.

Gupta, M. (2018). Reflections on medical law and ethics in India. Indian Journal of Medical Research, 147(2), 213.

Hollnagel, E., Wears, R. L., & Braithwaite, J. (2015). From Safety-I to Safety-II: a white paper. The resilient health care net: published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia.

Horner, G. N., Agboola, S., Jethwani, K., Tan-McGrory, A., & Lopez, L. (2017). Designing patient-centered text messaging interventions for increasing physical activity among participants with type 2 diabetes: qualitative results from the text to move intervention. JMIR mHealth and uHealth5(4), e6666.

Julie, G. N. (2015). A model of teacher professional knowledge and skill including PCK: Results of the thinking from the PCK Summit. In Re-examining pedagogical content knowledge in science education (pp. 28-42). Routledge.

McDonald, F., & Then, S. (2019) Ethics, law & health care: a guide for nurses and midwives (2nd ed.) (p. 180 & p. 270). Red Globe Press.

Mullan, J., Burns, P., Mohanan, L., Lago, L., Jordan, M., & Potter, J. (2019). Hospitalisation for medication misadventures among older adults with and without dementia: A 5‐year retrospective study. Australasian Journal on Ageing38(4), e135-e141.

Olejarczyk, J. P., & Young, M. (2019). Patient Rights And Ethics. National Library of Medicine; StatPearls Publishing.

Ossenberg, C., Mitchell, M., & Henderson, A. (2020). Adoption of new practice standards in nursing: revalidation of a tool to measure performance using the Australian registered nurse standards for practice. Collegian27(4), 352-360.

Rappaport, D. I., & Selbst, S. M. (2019). Medical errors and malpractice lawsuits: impact on providers—part 2 of 6. Pediatric Emergency Care35(6), 440-442.

Stievano, A., & Tschudin, V. (2019). The ICN code of ethics for nurses: a time for revision. International nursing review66(2), 154-156.

Wyder, M., Bland, R., Blythe, A., Matarasso, B., & Crompton, D. (2015). Therapeutic relationships and i nvoluntary t reatment o rders: Service users’ interactions with healthcare professionals on the ward. International Journal of Mental Health Nursing24(2), 181-189.

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