400777 Leadership For Quality And Safety In Health Care

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400777 Leadership For Quality And Safety In Health Care

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400777 Leadership For Quality And Safety In Health Care

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Course Code: 400777
University: Western Sydney University

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Country: Australia

Critical Reflection Essay

Article: Coroner recommends changes after blood mix-up patient death
The South Australian coroner has recommended carers and relatives be encouraged to accompany heart patients to pre-surgery procedures.
This comes after a 71-year-old patient died when she received a transfusion of the wrong blood type.
Prior to her heart surgery Ruth Stoll was required to go to Clinpath Laboratories to give a sample of blood so it could be tested in case she needed a transfusion.
She was there with another patient Martha Kovendy.
The one nurse in turn took blood from both women but, as the coroner found, she mislabelled the two test tubes.
Ms Stoll did require a transfusion during her operation but received the wrong blood. She died six days later.
Coroner Wayne Chivell recommended carers should be present at these pre-operative procedures.
Ms Stoll’s sister-in-law and Ms Kovendy’s husband remained outside in the waiting area while the blood samples were taken.
The coroner said heart patients are often very anxious and do not communicate well. The presence of carers would minimise the risk of error or confusion.
Aim of assessment
Standard 1 of the NMBA Registered Nurse Standards for Practice outlines the requirement for nurses to use best available evidence for safe, quality practice and to develop that practice through reflection on experiences, knowledge, actions, feelings and beliefs. The aim of this essay is for students to critically reflect on a nursing related event reported in the media and, using the NSQHS standards developed by ACQSHC (Australian Commission for Quality and Safety in Healthcare), identify what nurses might do to improve their practice and reduce the risk of a similar error.
Using the GIBBS Reflective Cycle (Gibbs, 1988), reflect on this nursing-related event. Students will write an appropriately structured essay that includes the following:
A comprehensive description of the critical incident.
An explanation of how the event made you feel and why it made you feel this way.
Evaluate the consequences of this critical incident for the health consumer (patient and their family).
Analyse the implications of this critical incident for your future nursing practice.
Identify and discuss new knowledge gained from this incident.
Develop an action plan to enhance your own learning from this incident.


Though nursing errors in clinical settings are inevitable, mislabeling of blood samples, and conducting blood transfusions with the wrong blood are errors whose results in most cases end up being catastrophic. This essay will, therefore, focus on effects of wrong blood transfusion and the various nursing interventions available to remedy it based on Ms. Stoll’s case study. Ruth Stoll, a 71-year old patient who was a victim of such errors (ABC-NEWS, 2003). Prior to undergoing a heart surgery, she was taken through Clinpath laboratories for blood samples to be collected. Such samples would be used to guide on the right blood for her should there be a need for blood transfusion.
In the lab was another patient, Martha Kovendy, whose blood samples were also being collected. However, there was only one nurse on duty and was tasked with the duty of collecting samples from both patients, labeling them appropriately and performing the required tests. After the nurse had collected the two samples, however, she mistakenly interchanged the labels. Ruth’s blood was therefore labelled as Martha’s and vice versa. During the surgery process, Ms. Stoll had to receive blood but received the wrong blood as it was based on Martha’s sample. Unfortunately for Ms. Stoll, complications arose as a result of the blood incompatibility. She succumbed to the complications six days later and passed away (ABC-NEWS, 2003).
This event made me develop a feeling of remorse and sadness. I maintain strong beliefs that no single patient under the care of clinical personnel should die as a result of the personnel’s mistakes. I was also overwhelmed by the fact that the incident could have been easily avoided had proper measures been implemented. Partnering with Consumer Standard is one of the National Safety and Quality Health Service Standards that was overlooked in this scenario. It calls for patients and consumers of healthcare be involved in designing, delivering and evaluating health care services. Had this standard been followed, Ms. Stoll’s husband and sister-in-law, who were outside when the blood samples were being taken ought to have been present during the whole exercise. Had they been present, they would have noted when the nurse was wrongly labeling test tubes with blood samples and corrected her.
The consequences of Wrong Blood in Tube (WBIT) are lethal to the consumer. Unfortunately, a majority of WBIT events only become apparent only when a transfusion reaction occurs. When the wrong blood transfusion was conducted on Ms. Stoll, what followed was an ABO incompatibility reaction (Colledge & Boskey, 2017). Her immune system subsequently reacted adversely to the blood group A antigens introduced in her body for she was of blood group O category. By her being a universal donor bur only potential of receiving blood from blood group O, her immune system reacted by attacking the type A blood cells introduced in her body. As a result of the aforementioned, blood clotting occurred throughout her entire circulation system (H, Bolton?Maggs, Wood, & Wiersum?Osselton, 2014). Subsequently, the supply of blood to all body organs including the vital ones such as the heart was cut. What followed was stroke and subsequent death.
Ms. Stoll’s relatives, on the other hand, underwent traumatizing experiences that have certainly never occurred in their lives before. It is sad and disheartening when family members learn that the cause of their beloved one’s death was not the problem that had necessitated her hospitalization but rather errors from staffs’ activities (Berlot, Delooz, & Gullo, 2012). It is most likely that they developed negative attitudes towards the hospital and all its personnel; all as a result of one person’s error. It is also most likely that they will discourage other relatives and friends who may want to seek medical care from the hospital. Should any of Ms. Stoll’s family members get hospitalized in future, carers monitoring them are more likely to be more cautious and seek participation as stipulated by the Partnering with Consumers Standard.
This incident has borne several implications for the future of my nursing practice. It will therefore be my responsibility to adhere to guidelines from the Nursing and Midwifery Board of Australia as well as NSQHC standards as set by the Australian Commission on Safety and Quality in Health Care. First, it has come to my understanding that it is my duty to ensure that all laboratory samples are labeled in ways that are distinct from other samples. Also, upon collecting a sample from an individual patient, I have learned that I should first label the test tube with the patient’s identification details before proceeding to collect samples from other patients to avoid chances of confusion. Before commencing a transfusion, I will always make sure that an order for the transfusion exists (Bielefeldt, 2010). Necessary equipment will always be at hand for the administration of blood product and to effectively counter a reaction should it occur. An additional I.V line for a normal saline solution and a hypersensitivity kit are some of the equipment that I will always avail during blood transfusions.
Following this incident, I have also dug deeper into the various National Safety and Quality Health Service Standards in attempt to seek their guidance on how I will successfully prevent the occurrence of such an accident during my practice. I will, therefore, implement the Preventing and Controlling Healthcare-Associated Infection Standard to minimize risks of patients under my care acquiring healthcare-associated infections that could result from the wrong blood transfusion (Dougherty, Lister, & West-Oram, 2015). Blood management standard will also be at the epicenter of my practice as a registered nurse when conducting transfusions and collecting blood samples. However, all the NSQS standards carry equal weight and will, therefore, be implemented during my nursing practice whenever relevant.
I have additionally developed a favorable action plan that will enhance my learning from this incident. I have marked it as my core objective to read and clearly understand all NSQS standards. I will also read relevant peer-reviewed academic materials to empower myself with information previously coined to curb such incidents.
In conclusion, this essay has highlighted the entire scene where a patient died as a result of wrong blood transfusion. Documented also are the consequences of the transfusion on the patient’s health as well as all the possible reactions that could have been developed by the patient’s relatives. Various nursing interventions with the potential to prevent re-occurrence of such an incident have been highlighted.
ABC-NEWS. (2003, Mar 12). Coroner recommends changes after blood mix-up patient death. ABC NEWS. Retrieved Aug 2018, from https://www.abc.net.au/news/2003-03-12/coroner-recommends-changes-after-blood-mix-up/1816102
Berlot, G., Delooz, H., & Gullo, A. (2012). Trauma Operative Procedures (illustrated ed.). Springer Science & Business Media.
Bielefeldt, S. (2010, April). The rules of transfusion: Best practices for blood product administration. AMERICANNURSETODAY, 5(4). Retrieved Aug 10, 2018, from https://www.americannursetoday.com/the-rules-of-transfusion-best-practices-for-blood-product-administration-2/
Colledge, H., & Boskey, E. (2017, May 2). ABO Incompatibility Reaction. Healthline. Retrieved Aug 10, 2018, from https://www.healthline.com/health/abo-incompatibility
Dougherty, L., Lister, S., & West-Oram, A. (2015). The Royal Marsden Manual of Clinical Nursing Procedures (illustrated ed.). John Wiley & Sons.
H, P., Bolton?Maggs, B., Wood, E. M., & Wiersum?Osselton, J. C. (2014, Oct 4). Wrong blood in tube – potential for serious outcomes: can it be prevented? Wiley Online Library, 168(1). Retrieved Aug 10, 2018, from https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.13137

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