Critical Reflection on Nursing Event: Blood Mix-up Patient Death

This essay presents a critical reflection on an event related to nursing domain that has been reported previously in media with the help of NSQHS standards. The article selected is titled as ’Coroner recommends changes after blood mix-up patient death’ and the NSQHS standard selected is Standard 2- Partnering with Consumers for this assessment item.

Running head: NURSING
Nursing
Name of student:
Name of university:
Author note:

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The Registered Nurse Standards for Practice, set in place by the developed by ACQSHC
(Australian Commission for Quality and Safety in Healthcare), outlines the fundamental
requirements for nurses to engage in safe and effective care practice for ensuring better patient
outcomes. Reflection on knowledge and skills is critical in this regard. The aim of the present
essay is to carry out a critical reflection on an event related to the nursing domain that has been
reported previously in media with the help of NSQHS (National Safety and Quality Health
Service) standards. The article selected is titled as ’Coroner recommends changes after blood
mix-up patient death’ and the NSQHS standard selected is Standard 2- Partnering with
Consumers for this assessment item. Gibb’s model of reflection is used for presenting the essay
in a logical and systematic manner.
The article titled ‘Coroner recommends changes after blood mix-up patient death’
published in the year 2003 reported that the South Australian coroner had recommended that
relatives and carers are to be encouraged to have their presence with patients of cardiovascular
system disorder prior to pre-surgery procedures. The recommendation had come forward after a
misfortunate event was reported regarding the death of a 71 year old patient after receiving blood
transfusion of incorrect blood group. Prior to the surgical procedure, the patient named Ruth
Stoll had to present at the Clinpath Laboratories for providing blood sample in order to undergo a
test for assessing the need of transfusion. Ruth presented at the laboratory with another patient
Martha Kovendy. Ms Kovendy's husband and Ms Stoll's sister-in-law were waiting outside in the
waiting area at the time of collection of the blood samples. The nurse responsible for taking
blood samples had mislabeled the two tubes. As per the reported incident, Ruth Stoll was in need
of a transfusion at the time of surgery but was provided with incorrect blood. This was due to the
error made at the nurse’s end while labeling the two blood samples. Transfusion with incorrect

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blood group resulted in the patient’s death after six days of undergoing the cardiac surgery
(mobile.abc.net.au, 2003).
The event reported was of much relevance to nursing practice and I feel sorry for such
incidents that commonly occur across the country, most of which are unreported. I believe that
the unfortunate event that has been reported could have been avoided at the very first place,
eliminating the risk of undesirable outcomes for the patient. In my opinion, cardiac patients and
those suffering from critical health conditions are often subjected to anxiousness, and are not in a
position to communicate in a proper manner. The presence of care givers holds the potential to
minimize the risk of confusion and errors (Conway et al., 2017). Partnership with healthcare
consumers would ensure that safe and high quality care is presented to the consumers. As per the
NHQHS standard 2, partnering with health care consumers ensure that benefits are brought about
to patients and healthcare providers alike. The standard entails professionals to work with
patients and their family members following the core principles of collaboration and
participation (safetyandquality.gov.au, 2012). As per my understanding, when family members
are involved in the care process of the distinct patients presenting with complex care needs, the
benefits outweigh the risks of harms. Family centered and person centered care can be provided
when such involvement is there, as opined by (Feinberg, 2014). The researchers had commented
that there is growing evidence pointing out the need of partnerships between carers, families,
consumers and patients. Increase in patient safety, patient satisfaction, and cost effectiveness can
be enabled when carers are involved. In this regard Tobiano et al., (2015) had stated that
operational benefits of delivering care are immense, including decreased readmission rates,
decreased mortality, reduced hospital stay and better functional status. Operation benefits would
involve better liability claims and lower care costs per case.

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In the present scenario, the consequences of the error made by the nurse had an adverse
impact on the whole, that is patient death. While the patient outcome expected out of a cardiac
surgery could not be reached, the impact of the event on the family member was also
noteworthy. Since Ms Stoll’s sister-in-law was present outside the laboratory in the waiting
room, she was likely to suffer from regret that she could not aid in the process of blood
collection. Analyzing the consequence on patient and family members, it can be stated that poor
health outcomes for patients, and stress and emotional burden on families can be avoided by
having proactive approach for healthcare partnerships (Black, 2016).
Analysis of the incident has a profound effect on personal nursing practice. Drawing
insights from the incident I conclude that nurses have the responsibility of providing safe care to
patients, which can be enable by involving families who are primary carers. As a nurse, I hold
the responsibility of respecting the preferences of patients while planning a certain procedure.
Involvement of family members of patients in informed decision making is crucial (Kearney-
Nunnery, 2015). Supporting patients to raise voice against concerns regarding the process of care
provided is also elementary (Porney et al., 2015).
The knowledge gained from the incident and subsequent analysis is immense. Partnership
with care givers to patients, such as families can ensure that input for the respective individuals
is guides better care delivery. Such inputs can lead to reduced length of stay at hospital,
improved adherence to medical management regime, and decreased rate of readmission to care
units. Leaders of health care units must implement systems for supporting such collaboration.
Effective policies are to be set in place so that healthcare workers are obliged to follow the
principles of care provider-consumer collaboration. The key understanding is that patients are to
be placed at the centre of care in a more general manner.

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At this juncture an action plan is being outlined for future professional practice. In future
nursing practice, involvement of family members would be considered in patient care wherever
possible. Special consideration would be given to ensure presence of family members at the time
of collection of blood samples from patients. While articulating treatment plan to patients it
would be elementary to have a family member present at the site. This would help in receiving
input of the individuals, and the same is crucial since involvement of family focuses on
adjustments in relation to diagnosis of the patient condition and clarification of treatment options
(Black, 2016).

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References
Black, B. (2016). Professional Nursing-E-Book: Concepts & Challenges. Elsevier Health
Sciences.
Conway, P. H., Coyle, S., & Sonnenfeld, N. (2017). Partnership for patients: Innovation and
leadership for safer healthcare. Journal of Healthcare Management, 62(3), 166-170.
Feinberg, L. F. (2014). Moving toward person-and family-centered care. Public Policy & Aging
Report, 24(3), 97-101.
Kearney-Nunnery, R. (2015). Advancing Your Career Concepts in Professional Nursing. FA
Davis.
National Safety and Quality Health Service Standards. (2012). Retrieved from
https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-
Sept-2012.pdf
Coroner recommends changes after blood mix-up patient death. (2012). Retrieved from
http://mobile.abc.net.au/news/2003-03-12/coroner-recommends-changes-after-blood-
mix-up/1816102?pfm=sm&pfmredir=sm
Pomey, M. P., Hihat, H., Khalifa, M., Lebel, P., Néron, A., & Dumez, V. (2015). Patient
partnership in quality improvement of healthcare services: Patients’ inputs and challenges
faced. Patient Experience Journal, 2(1), 29-42.
Tobiano, G., Marshall, A., Bucknall, T., & Chaboyer, W. (2015). Patient participation in nursing
care on medical wards: an integrative review. International Journal of Nursing
Studies, 52(6), 1107-1120.