Clinical Decision Making

CBT Assignment
April 23, 2024
April 23, 2024
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Clinical Decision Making

Medical errors and unwanted outcomes occur due to the environment common in most healthcare facilities that involves complex diseases, technologies, policies, resources, procedures and the human factor. In healthcare settings, medication errors occur approximately in every 1 out of 20 medication administrations (Bates et al., 1995). One such situation occurred in a surgical ward where one patient had an insulin shot due. The nurse I was shadowing drew up the shot but needed another nurse to verify the dose according to the hospital policy. However, since it was a busy hour and all nurses were busy, she proceeded to give the injection and decided to document afterwards. Later, she found a nurse who signed off on the procedure despite not having seen the actual dose being administered.
From school lectures and research, I have learnt that it is necessary for clinicians to observe the six rights of proper administration of medication, one of which is the right dose (Smeulers et al., 2015) in order to avoid medication errors. Research has shown that double-checking before administering insulin shots resulted to fewer medication errors (Modic et al., 2016). After one incident was reported to the charge nurse, the decision to make the two-nurse verification for insulin shots mandatory was implemented, supported with the above evidence. Additionally, another common issue in hospital environment is catheter-related urinary tract infections which accounts for about 30% of all infections in hospitals (CDC, 2015). Evidence-based practice recommends strategies to improve this outcome including; proper catheter use and maintenance, proper obstruction management and proper surveillance. The application of these strategies is more important simply because of the higher occurrence of infections as stated earlier. When implemented, evidence has shown to drastically reduce infection rates and improve health outcomes.


Bates, D., Boyle, D., Vliet, M., Schneider, J., &Leape, L. (1995). Relationship between medication errors and adverse drug events. Journal Of General Internal Medicine10(4), 199-205.

CDC. (2015). Guideline for Prevention of Catheter-Associated Urinary Tract Infections. Retrieved 30 April 2021, from

Modic, M., Albert, N., Sun, Z., Bena, J., Yager, C., & Cary, T. et al. (2016). Does an Insulin Double-Checking Procedure Improve Patient Safety?. JONA: The Journal Of Nursing Administration46(3), 154-160.

Smeulers, M., Verweij, L., Maaskant, J., de Boer, M., Krediet, C., Nieveen van Dijkum, E., & Vermeulen, H. (2015). Quality Indicators for Safe Medication Preparation and Administration: A Systematic Review. PLOS ONE10(4), e0122695.