Nursing Reflection on Blood Transfusion Error: A Case Study

This essay discusses a nursing event that led to death of a patient after mixing of blood. It uses Gibb’s reflective cycle to analyse the event and illustrates the NMBA Standards for Practice regarding safe and efficient care. The incident highlights the importance of accurate identification and labelling of patient specimens to prevent medical errors.

Running head: NURSING REFLECTION
Coroner inquest
Name of the Student
Name of the University
Author Note

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Introduction- Mixing of wrong types of blood during blood transfusion often result in
patient death (Murphy, Waters, Wood & Yazer, 2013). This essay will use Gibb’s reflective
cycle to discuss a nursing event that led to death of a patient after mixing of blood. The event
involved an elderly patient who was transfused with blood of a different group that
subsequently resulted in her death. The event can be categorised as a severe form of medical
error that occurred due to mislabelling of the blood samples. It is recommended by the
Australian Commission for Quality and Safety in Healthcare (ACQSHC) to adopt national
initiatives that work towards improving the quality and safety of medication use.
Furthermore, the essay will also illustrate the NMBA Standards for Practice regarding safe
and efficient care.
Description- In 2003, Ruth Stoll, a 71 year old lady died upon receiving wrong blood
type transfusion. She was taken to the Clinpath Laboratories before her cardiac surgery, in
order to give blood sample for the transfusion process that was to follow. Martha Kovendy,
another patient was also present there. While taking blood from both the patients, the nurse
mislabelled the tubes. Although Ruth needed blood during the surgery, transfusion of wrong
blood type resulted in her death, six days later. During collection of the blood sample, her
sister-in-law and husband were not allowed to enter the room, and were kept waiting outside.
Feelings- I was upset and astounded to learn of the death of Ruth Stoll. My initial
feelings were a mixture of disbelief and astonishment of the callousness and negligence of the
nurse in charge. I became quite sceptic and tried to understand the reasons that made the
nurse commit such a grave mistake of not labelling the blood types accurately. I could not
ascertain as to how can a nursing professional be so negligent towards her duties and be a
part of an act that directly threatened the safety of the client. The incident made me extremely
sad and overtly distressed owing to the fact that I have always considered my job as a nursing
professional to be the forefront of care that is delivered to any patient. My clinical expertise

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and experience have enforced my belief that we as nurses have the responsibility that can
create substantial impacts on the safety of our patients. Owing to the fact that nursing
professionals are crucial in ensuring health and safety of all service users, the act performed
by the nurse in question created a feeling of shame and disgust (Shekelle, 2013).
Evaluation- The direct consequence of this event can be associated with death of
Ruth Stoll, due to an avoidable incident. The very requirement that is expected of all
healthcare organisations and professionals is to avoid practicing any event that can harm the
patient. ‘Do no harm’ has often considered a prerequisite for delivery of optimal care
services, with the aim of improving patient health (Scott, Anderson, Freeman & Stowasser,
2014). However, an analysis of the incident suggests the presence of poor vigilance and
monitoring of patients before a surgery. Although all health service agencies illustrate their
role in focusing on improvement of patient health, the incident was a clear indication of the
negligence and lack of reasonable care to ensure health and safety of the patients (Wachter,
Pronovost & Shekelle, 2013). Furthermore, inclusion of her family members in the room
might have prevented the incident by drawing attention of the nurse to the error that got
overlooked. The standard 6 makes it imperative for RN to provide a safe and comprehensive
quality practice for achieving agreed outcomes and goals for all patients, while working in
the scope of their practice (NMBA, 2018). Furthermore, they are also required to report and
identify actual and potential risk that might threaten patient safety.
Analysis- Ensuring accurate identification of a patient is crucial to prevent all types of
medical errors. Failure to detect the mislabelling or abnormal act in a laboratory, makes the
error remain undiscovered, till the atypical results are questioned by a clinician. This is a
major form of pre-analytical error and has the potential of jeopardising health and safety of
the patients (Karcher & Lehman, 2014). Thus, proper labelling of all specimens act as critical
components of accurate and effective patient care. Timely and accurate labelling of all

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specimens is an essential pre-examination step for nurses (Novis, Lindholm, Ramsey, Alcorn,
Souers & Blond, 2017). Avoidable errors as those in the scenario that led to death of the
patient can be prevented by labelling the test tubes initially, followed by withdrawing blood
from each patient one at a time, and collecting them in the marked tubes (Van Leeuwen &
Bladh, 2017). Moreover, I will also develop a partnership with the patient, his/her carers and
workforce members as per the standards 2, with the aim of designing a health service that
shows responsiveness to the needs and inputs of the carer and the consumer. I intend to abide
by the standard 5 of ACQSHC that focuses on the importance of ensuring accurate
recognition and matching of patients. Furthermore, I also wish to show adherence to the
standard 7 that ensures efficient use of blood and its products. Appropriately documenting
patient information and safely managing blood and blood products will help me to avoid any
such adverse incidents in my practice (Safetyandquality.gov.au, 2018).
Conclusion- To conclude, nurses have the role of accurately identifying and labelling
patient specimens. Failure to do so can portend serious harm to the health of the patient and
might also result in death, as was seen in the case of Ruth Stoll. Moreover, medical errors are
one of the most common types of health intimidating mistakes that create a direct impact on
patient care.
Action plan- I learnt that although errors are an integral part of human life, execution
of proper medical orders is an essential prerequisite to the role of a healthcare professional.
This event could have been easily avoided, had the nurse in charge not mislabelled the blood
specimen of Ruth Stoll and Martha Kovendy. Medical errors can occur due to negligence of
any member of a healthcare team, but nursing professionals execute most of the medical
orders due to the fact that they spend more time with the patients. Avoiding medical errors
will help in enhancing patient safety and result in a reduction in any kind of hazard (NMBA,
2018).

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References
Karcher, D. S., & Lehman, C. M. (2014). Clinical consequences of specimen rejection: a
College of American Pathologists Q-Probes analysis of 78 clinical
laboratories. Archives of Pathology and Laboratory Medicine, 138(8), 1003-1008.
https://doi.org/10.5858/arpa.2013-0331-CP
Murphy, M. F., Waters, J. H., Wood, E. M., & Yazer, M. H. (2013). Transfusing blood safely
and appropriately. BmJ, 347(F4303), 1-12. doi: 10.1136/bmj.f4303
Novis, D. A., Lindholm, P. F., Ramsey, G., Alcorn, K. W., Souers, R. J., & Blond, B. (2017).
Blood Bank Specimen Mislabeling: A College of American Pathologists Q-Probes
Study of 41 333 Blood Bank Specimens in 30 Institutions. Archives of pathology &
laboratory medicine, 141(2), 255-259. https://doi.org/10.5858/arpa.2016-0167-CP
Nursing and Midwifery Board of Australia. (2018). Registered nurse standards for practice.
Retrieved from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-
Statements/Professional-standards/registered-nurse-standards-for-practice.aspx
Safetyandquality.gov.au. (2018). National Safety and Quality Health Service Standards.
Retrieved from
https://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-
Standards-Sept-2012.pdf
Scott, I. A., Anderson, K., Freeman, C. R., & Stowasser, D. A. (2014). First do no harm: a
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Shekelle, P. G. (2013). Nurse–patient ratios as a patient safety strategy: a systematic
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Van Leeuwen, A. M., & Bladh, M. L. (2017). Davis's comprehensive handbook of laboratory
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DOI: 10.7326/0003-4819-158-5-201303050-00010