Example Reflective Account: Medication Near-Miss (Code Section 18)

The second worked example. A medication near-miss caught before administration. Code Section 18 (medicines administration).

The example is anonymised and based on the common patterns audit auditors see in strong submissions on medication-related learning.

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Form 6: Reflective Account 2 of 5

Date completed: April 2025 Date of event: February 2025

Field 1: What was the nature of the CPD activity, practice-related feedback, or event in your practice?

On a late shift in February 2025, I was administering medications on an adult medical ward. The patient was a man in his 60s with chronic kidney disease who had been started on a new course of antibiotics that morning. The prescription was for an antibiotic at a dose that was the standard adult dose, not the renally-adjusted dose.

I drew up the prescribed dose. Before administering, I rechecked the BNF for the antibiotic and noted that for the patient’s eGFR — which I had seen on the electronic record that morning — the dose should have been roughly 60% of what was prescribed. I held the medication, called the prescribing junior doctor, and the prescription was amended within 15 minutes. The patient received the correct reduced dose.

The original prescription had been written overnight by a different doctor, and the prescribing context had been a sepsis screen where the immediate priority had been antibiotic cover rather than renal adjustment. The eGFR result had landed after the prescription was written.

Field 2: What did you learn from the CPD activity, feedback or event?

The learning had two layers.

The narrower insight was that I had been treating renal adjustment as something I checked at the start of a patient’s stay, not before every administration. Renal function changes — and prescription windows that were correct on admission can become incorrect later in the stay as eGFR moves. The recheck habit needs to be per-administration, not per-admission.

The wider insight was about the working assumption behind drug rounds. I had been operating on a default of “the prescription is right, my job is to administer it accurately”. The near-miss showed me that the right default is “the prescription is right unless I see something that says otherwise” — which sounds the same but operates differently. The first version doesn’t trigger a check unless something looks obviously wrong. The second triggers a check on every drug whose dose depends on patient parameters I can see in the record (renal function, weight, age, INR).

Field 3: How did you change or improve your practice as a result?

Two changes since February.

First, for any drug with renal adjustment rules, I now check the most recent eGFR before administration, not just at the start of the patient’s stay. I have caught one other near-miss in the eight weeks since the change — a different antibiotic on a different patient where the dose had been calculated against an older eGFR.

Second, I now use a deliberate slow-down before administering any drug whose dose depends on patient parameters. The pause is maybe five seconds: I name to myself the parameter the dose depends on, recall what the parameter is for this patient, and confirm the dose makes sense. The five seconds doesn’t slow the round noticeably but has caught the second near-miss and prevented two prescriber-side queries.

Field 4: How is this relevant to The Code?

Code Section 18: Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence.

Sub-clause 18.1 requires medicines administration within the limits of competence; sub-clause 18.3 requires care that is compatible with other treatment the patient is receiving. The deliberate pause and parameter-recheck habit addresses both — the pause ensures I’m not administering a dose I haven’t verified is appropriate, and the recheck ensures the dose is compatible with the patient’s current renal function rather than their admission state.

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Why this example works

Specificity throughout. The event has named specifics: patient demographics, the type of drug class, the parameter that mattered (eGFR), the time gap between prescription and result.

A specific insight in Field 2 that isn’t just “be more careful”. The shift from per-admission to per-administration checking, and the shift in default assumption, are both concrete cognitive moves the registrant can describe and the audit can verify.

Behavioural change with evidence of holding. Two distinct changes, both with examples of catching subsequent issues. The “second near-miss caught” line is the strongest single piece of evidence that the change is real.

Section 18 link that quotes specific sub-clauses and connects them to the behavioural change.

What makes this safe to write

The original near-miss was caught and reported through the appropriate incident system. The patient came to no harm. The reflection is on learning from a near-miss, not on undisclosed harm. This is the kind of reflection the NMC actively encourages: turning a near-miss into a behavioural shift.

If the audit queried the account, the supporting evidence would be the incident report and the prescription correction trail in the electronic record.

The next chapter contains the third worked example: a reflective account on Code Section 19 (reduce risk of harm) covering an infection control incident.