Essay on Safety and Quality Health Service

CRITICAL REFLECTION ESSAY

TABLE OF CONTENTS
INTRODUCTION...........................................................................................................................1
Essay................................................................................................................................................1
REFERENCES ...............................................................................................................................5

INTRODUCTION
The safety and quality health standards aim at protecting public from harmful impacts
and possible risks of health care services which may occur due to negligence of registered nurses
or health care providers. These standards also provide guidelines to improve the quality of health
services.
The essay will analyse the case study of patient's death due to negligence in clinical
practices. It will highlight the implications of these negligences and clinical errors by using
critical reflection approach in essay. The report will also explore the consequences of the given
incident and its implications. It will analyse the role of partnering with consumer standards of
safety and quality health. The critical reflection in practices and analysis will create more
influence on defining social perspective and to find better solutions for the issues (Jim and John,
2012).
Essay
In 2001 Ms Ruth Sophie Stoll and Mrs Kovendy, both were present at Clinpath
Laboratories for their blood tests. Ms Stoll was required to have blood test so that during her
heart surgery if she required blood transfusion then hospital could have arranged the same. Both
of the patients were served by registered nurse (RN) Sally Gilbert. During the sample testing, she
was the only RN present at that moment in lab, thus she attended both of them simultaneously.
During sample collection of blood from both the patients, RN Sally Gilbert mislabelled both the
samples. During surgery blood transfusion was required for Ms Stoll but as samples were
mislabelled in laboratory by RN Gilbert wrong blood match was provided to her. As a result of
this, Ms Stoll suffered from organ failure. Ultimately after few days of her surgery, she died due
to the confusion and improper identification of blood samples. At the time of sample collection
the carers of both of the patients were waiting outside. Coroner Wayne recommended that if
family members and carers were present inside the room during pre operative procedures then it
could have eliminated the error. According to Coroner the heart patient find it difficult to
communicate due to anxiety. Thus, in such cases the presence of carer can help service providers
to avoid possibilities of such errors.
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The incident demands for more attention towards family participation in pre operative
stages and high level of precautions in clinical practices. Ms Stoll could have survived if wrong
blood sample was not transfused to her and RN have shown some more caution in her practices.
As per the observations made by Coroner an identification mistake by RN while collecting and
labelling blood sample caused such huge loss. I am shocked from this incident because we all
have faith in our health professionals and we give them authority to handle our life. Thus, it is
the legal responsibility of health professionals to execute clinical activities with precautions and
care (Dehghani, Mosalanejad and Dehghan-Nayeri, 2015). RN Sally Gilbert must have shown
appropriate concern and responsibility while collecting samples. If she had some doubts
regarding the identification of blood samples then, she must have taken the sample again so that
Ms Stoll could have been saved. With this incident, I will find it difficult to trust health care
professionals and will always have fear that they might commit an error during diagnosis of
disease or samples.
The death of Ms Stoll due to incorrect sample identification and diagnosis by RN has
caused irreversible losses to the family of Ms Stoll. But the incident has also caused severe
implications on patients and their carers. As per my view, it will become difficult for them to
maintain the faith on health professionals. People will hesitate to access health care facilities and
will not encourage awareness about health care practices. The families of patients will now
become more conscious about the practices by RN and will always have concerns about the
accuracy of their practices.
However, I believe this incident will also bring positive changes by introducing more
sensitivity and understanding in health care practices. It demands that health care professionals
must be more careful in their practices as they have great responsibility of securing lives of
people. As per the recommendations made by Coroner the carers of patients must accompany the
patient because it may happen that due to anxiety or stress patient may not give accurate
information. Such types of errors can be minimized and quality of health care services can be
improved by implementing the concept of consumer partnership. According to family centred
care approach and consumer partnership standard the carers and patient's can avoid such
hazardous errors by providing more clear and concise information (Coyne, 2015). For instance, if
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carer of Ms Stoll had accompanied her then they could have identified the mistake of RN and the
incident could have been avoided.
The incident has taught me a great lesson that nurses must be careful and attentive while
executing clinical practices. In future I will try to ensure that when I will have excessive work
pressure then also I will ensure that I must not make mistakes in order to complete tasks. I will
include patients and their families in decision making. The equal participation of carers and
patient's in health care services and procedures will help me to serve with more accuracy.
As per my point of view the major findings from the given incident is that the errors in
health care facilities can be minimized if patients and carers also take part in decision making
and provide completed and accurate information to the professionals. They can minimise the risk
of clinical errors by accompanying patients for providing them emotional support and relaxation
from anxiety and fear. The partnership of families along with patients will help health
professional to avoid errors as well as to develop better understanding of condition of patients.
From the incident, I have also observed that RN was alone at that time in clinic so she tried to
collect samples one after the other in hurry and it leads to the mislabelling of samples. Thus,
health service providers must also ensure that they effectively manage the work load of
professionals and remain calm and concentrated so that they can provide services according to
quality standards without possibility of errors (Hobbs and et.al., 2016).
Such incidents can be avoided if registered nurses and other health professionals
compulsorily involve the carers in decision making and clinical practices. The health service
providers must make attempts which allow professionals to provide services without errors or
burden. In certain practices, regular monitoring and cross checking can also help to learn from
the incident.
From the essay it can be concluded that it is necessary for health professionals to provide
services with due care and as per the safety and quality standards of health. The report has
explained various implications and consequences of incident which caused death of a patient due
to inaccurate practice in labelling and identification by registered nurse. It can also be concluded
from the report that quality of nursing and health care practices that can be improved by
introducing standards of consumer partnership in health care services.
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REFERENCES
Books and Journals
Coyne, I., 2015. Families and health‐care professionals' perspectives and expectations of family‐
centred care: hidden expectations and unclear roles. Health expectations. 18(5). pp.796-
808.
Dehghani, A., Mosalanejad, L. and Dehghan-Nayeri, N., 2015. Factors affecting professional
ethics in nursing practice in Iran: a qualitative study. BMC medical ethics. 16(1). p.61.
Hobbs, F.R., Bankhead, C., and et.al., 2016. Clinical workload in UK primary care: a
retrospective analysis of 100 million consultations in England, 2007–14. The
Lancet. 387(10035). pp.2323-2330.
Jim.C and John.P, 2012., The British Journal of Social Work, Volume 42, Issue 8, 1 December
2012, Pages 1435-1439,doi-10.1093/bjsw/bcs191
Online
Coroner recommends changes after blood mix-up patient death, 2003. [Online] Accessed
Through <http://www.abc.net.au/news/2003-03-12/coroner-recommends-changes-after-
blood-mix-up/1816102>
National Safety and Quality Health Service Standards Second edition, 2017. [Online] Accessed
Through <https://www.safetyandquality.gov.au/wp-content/uploads/2017/12/National-
Safety-and-Quality-Health-Service-Standards-second-edition.pdf>
PARTNERING WITH CONSUMERS, 2017. [Online] Accessed Through
<https://www.safetyandquality.gov.au/wp-content/uploads/2017/11/Partnering-with-
Consumers.pdf>
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