Incompatible Blood Transfusion: Description, Evaluation, Analysis, Identification, And Discussion

Students must refer to the article titled ’Coroner recommends changes after blood mix-up patient death’ and NSQHS Standard 2 - Partnering with Consumers for this assessment item. They are located under the Assessments tab on the unit vUWS site in the Assessment 1 folder.
Using the GIBBS Reflective Cycle (Gibbs, 1988), reflect on this nursing-related event. Students will write an appropriately structured essay that includes the following:
1. A comprehensive description of the critical incident.
2. An explanation of how the event made you feel and why it made you feel this way.
3. Evaluate the consequences of this critical incident for the health consumer (patient and their family).
4. Analyse the implications of this critical incident for your future nursing practice.
5. Identify and discuss new knowledge gained from this incident.
6. Develop an action plan to enhance your own learning from this incident.
The essay may be written impersonally in third person, but students may choose to write the reflection in the first person.
Students should note that they cannot reference a personal reflective statement about how they felt, any actions they took or decisions they made. However, if they refer to the concepts and theories of 

Description

Reflection provides an opportunity for clinical reasoning while at the same time impacting on patient care positively (Chakkaravarthy, Ibrahim, Mahmud & Venkatasaly, 2018). Nursing is at the core of health care. Whether a student or a registered nurse, reflection provides an opportunity for growth for the nurses and thus enables them to pursue their endeavors of delivering quality health care to the patients. Reflection is crucial in helping the nurse adapt to the ever-changing work environment. Open-mindedness is required for effective reflection.  This write up will give a description, explanation, an evaluation, analysis, identification and discussion as well as the conclusion regarding the incompatible blood transfusion.

The incompatible blood transfusion

Description

Miss Ruth Stoll and Mrs Martha Kovendy met at Clinpath Laboratories where they gave blood samples. Miss Stoll was accompanied by her sister-in-law while Mrs Kovendy was accompanied by her husband. According to “ABC News”, 2003, Miss Stoll was giving the sample which could later be used in transfusion before her heart surgery if a need arose. The two ladies were attended to by a nurse. As the two ladies got attended to, those accompanying them waited for them in the waiting area. Nurses should give the right services to the patient. Therefore, the need for their supervision (Nursing and Midwifery board of Australia [NMBA], 2015).  The absence of supervision during transfusion led to mix-up of blood. The blood used on Miss Stoll caused her death.

Feelings

I felt angry. I regretted why I was pursuing a career in nursing. I wondered whether the nurse who attended to the patients was skilled enough. This incidence would not have occurred if the right procedures had been followed.

Evaluation

A patient who had gone to seek medical help only to die in the very place that she was seeking help? Family members who were looking forward to seeing either their mother or sister recuperate and get back home and a husband who earnestly waited for his dear wife to return home. This was the biggest drawback for that medical facility.

The thought of blood mismatch for a patient within the facility is horrific in itself to the family (Whitty & Littlejohns, 2015). Beyond the loss of a family member, their confidence in the health system and the safety of the patient got eroded. The medical facility needs to do much to redeem itself.

Analysis

Implications of incompatible blood transfusion to my future nursing practice

Life is sacred and must be preserved at all cost. The lack of caution on the part of the nurse who was taking the blood samples led to the loss of life. The negligence was singled out in poorly labelled test tubes, lack of recording of packaging bags and ignorance of the nurse on what she was exactly doing. Going forward, I will be very keen on how I handle issues in the health care facility. I need to go beyond the basic understanding of medical problems. The provision of quality services to the patient requires integrated approach where the patient is central to the system (Nursing and Midwifery board of Australia [NMBA], 2007).  I will engage a mentor who will guide me through my assignments as I enhance my competencies. Better service delivery will arise from my understanding of organisational policies and procedures as well as the National Safety and Quality Health Service Standards and their strict adherence.

Feelings

Identification and Discussion

I am now well informed about the consequences of individual actions. It is clear that once I am assigned a task, I should handle it thoroughly to its completion. The process of delivering health care should not cause harm to the patient (Nursing and Midwifery board of Australia [NMBA], 2010). The role of family members when it comes to supporting their ailing member is not limited to just escorting them to health centers, handing them to health personnel and then waiting for them outside, they should also be keen to see the procedures being carried out on their patients and whether they conform to the standards  (Banks, 2016). I would be willing to invite family members to see the care and treatment that I am giving to their patient.

Professional competency and adherence to policies and procedures are vital to delivering safe health care (Halcomb, Stephens, Bryce, Foley & Ashley, 2016). Since I understand that I have an ethical and moral obligation to preserve life, I would have passionately served the patients and labelled the blood samples appropriately. However, due to constraining regarding staffing I found out that I was the only nurse available and lunchtime was approaching very fast. As I tried to serve the patients hurriedly, I forgot to label the test tubes before placing the blood samples. Later I realised that the labelling of the test tubes was not correctly done. I thus need to improve on my communication and critical thinking skills which will enable me to communicate with the patients and get them relaxed as I attend to them. This will also help me to get composed and deliver quality services.  

Plan of Action

As a future registered nurse, I will improve on my competencies so that I can avert a similar error during a blood transfusion. This will be achieved through:-

An in-depth reading of the National Safety and Quality Health Service Standards so that I am at par with industry requirements on health,

Communication- this is the exchanging of information either through speaking, writing or by use of any other medium (Jandt, 2017).

Joining a Professional Nursing Organization- whatever I do or say should be guided by ethical principles and moral values (Harriss, 2014). I should be able to do the right things both to the patient as well as my colleagues. Joining a professional body will ensure that am at par with industrial requirements.

Conclusion

Health care management involves processes which need to be clearly understood. The success of the delivery of quality, efficient and safe services depends on the effectiveness of the system. When a patient visits a health centre, his or her problem will need to be diagnosed and described. The patients highlight their feelings for a diagnosis to be done. The caregiver then evaluates the feelings as well as the physique of the patient, analysis and gives treatment or recommends for further action.

References

Banks, M. (2016).  Improving The Safety And Quality Of Health Care For Aboriginal And Torres Strait Islander People Using The Australian National Safety And Quality Health Service Standards.

International Journal for Quality in Health Care, 28(suppl_1), 55-55.

Chakkaravarthy, K., Ibrahim, N., Mahmud, M., & Venkatasalu, M. R. (2018). Predictors for nurses and midwives' readiness towards self-directed learning: An integrated review. Nurse education today.        

Halcomb, E., Stephens, M., Bryce, J., Foley, E., & Ashley, C. (2016). Nursing competency standards in primary health care: an integrative review. Journal of clinical nursing, 25(9-10), 1193-1205.

Harriss, A. (2014). What Nursing and Midwifery Council revalidation means for OH nurses. Occupational Health & Wellbeing, 66(9), 27.

https://www.abc.net.au/news/2003-03-12/Coroner-recommends-changes-after blood-mix-up/1816102

Jandt, F. E. (2017). An introduction to intercultural communication: Identities in a global community. Sage Publications.  

Nursing and Midwifery Board of Australia. (2007) ‘National framework for the development of decision making tools for nursing and midwifery practice’. Retrieved 05 January 2015, www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Frameworks.aspx

Nursing and Midwifery Board of Australia (2010) ‘A nurse’s guide to professional boundaries’. Retrieved 05 January 2015, www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professionalstandards.aspx

Nursing and Midwifery Board of Australia. (2015) ‘Supervision guidelines for nursing and midwifery.Retrieved25September2015’,www.nursingmidwiferyboard.gov.au/Registration-and Endorsement/reentry-to-practice.aspx

Whitty, J. A., & Littlejohns, P. (2015). Social values and health priority setting in Australia: an analysis applied to the context of health technology assessment. Health Policy, 119(2), 127-136.