Nursing Reflection on Blood Transfusion Reaction Case Study

This nursing reflection is based on a case study of a fatal blood transfusion reaction. The Gibbs reflective cycle is used to analyze the case and highlight the importance of safe and competent nursing practice. The reflection also emphasizes the need for person-centered care and involvement of family members in the care plan.

Running head: NURSING REFLECTION
Nursing Reflection
Name of the Student
Name of the University
Author Note

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Introduction
Blood transfusion reactions are associated with severe adverse cases and at times
might lead to death (Sahu & Hemlata, 2014). The following assignment is based on a news
report that highlights fatal outcomes of the blood transfusion reaction. The assignment will
follow the Gibbs reflection framework in order to highlight the relevancy of the nursing
practice in relation to the case study. The importance of narrating the case study on the basis
of the Gibbs reflective cycle is highlighted in the 10th code of the nursing professional code of
conduct, Nursing and Midwifery Board of Australia (2017). According to this code, a nurse
must practice reflectively and ethically.
Gibbs Reflective Cycle
Description
The reports published by ABC News (2003), highlighted the story of the tragic death
of a 71-year old patient, Ruth Stoll due to transfusion of wrong blood during heart surgery.
The reports highlighted that Ruth Stoll was taken to Clinpath laboratories in order to give
blood sample for blood grouping. In Clinpath laboratories, Ruth Stoll was accompanied with
another patient, Martha Kovendy, who also went for blood grouping test. While taking the
samples, the attending nurse in the laboratory mislabelled the test tubes leading to the
swapping of the report between the two patients. At the time of surgery, Ruth Stoll are
required to provide external supply of blood and transfusion of mismatched blood ignited
blood transfusion reaction leading to the patient’ death within next 6 days. The coroner who
was investigating the case highlighted that at Clinpath Laboratories, Ruth Stoll was
accompanied with her sister in-law and Kovendy with her husband but both of them waited
outside while the collection of blood sample was done. Their presence might have turn the

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entire scenario in a completely different way. In relation to this unfortunate case, coroner
Wayne Chivell recommended that carers should be present during pre-operative procedures
in order to avoid medical service error. Coroner further opined that this recommendation is
extremely significant for elderly care or with heart patients as they remain anxious in most of
the time and fail to communicate well (ABC News, 2003).
Feelings
Reading the entire report made me feel extremely sad and at the same time very
disturbed. I felt that the negligence of that fellow nurse working in Clinpath Laboratories cost
life of Ruth Stoll. It is her carelessness or lack of proper concentration and unsafe practice
lead to such fatal outcome. Why I am feeling like this because, my though process is guided
with my professional values which promote me to practice as per the code of professional
conduct for nurses as published by nursing and midwifery board of Australia (NMBA).
According to the first standard of NMBA (2017), it is the duty of the nurse to practice in the
safe and competent manner. Here maintenance of competency includes improvement of
skills, knowledge and attitudes towards relevant practice in the clinical, educational and
research settings. Moreover, it is also the duty of the nurse to be aware about the activities he
or she is taking so that it might not compromise the safety of the patients.
Evaluation
The consequences of this incident have cost life of a person. If Martha Kovendy also
required blood transfusion then the casualty number might have increase further. The loss of
life of any member of the family is detrimental to the other members as it hampers their
mental state and well-being. According to Cowan and Hetherington (2013), sudden loss of
life of a family member creates extreme mental trauma over the carers of the family.
Moreover, death resulting from negligence of the health care professionals creates an anguish
and lack of faith over the entire healthcare system.

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Analysis
The main implications of the incident over my nursing practice, I will be more
diligent and focused while handling the patient’s sample of reports. According to Griffith
(2016) causality occurring from the nursing error, creates huge repercussion over the nursing
professionals which further affects the overall quality of care of other patients. Melvin (2015)
is of the opinion that in order to avoid manual errors in the nursing profession, the nursing
professionals are required to be focused even while handling huge workload and compassion
fatigue. This again goes with the standard 1 of NMBA code of conduct which encourage the
nursing professionals to practice in safe and competent manner. The implication of the
critical incident as discussed above are also guided by the standard 2 of National Safety and
Quality Health Service Standards (NSQHS), which promotes partnering and consumers. This
signifies that strategies are required to be generated that promotes person-centered health care
system that includes both the patients and their carers in the decision making process
(Australian Commission on Safety and Quality in Health Care, 2017). In case of Ruth Stoll,
the person centered care approach will include her family members. This is because,
Brännström and Boman (2014) highlighted that in aged care or caring aged patients with
cardiac patients, involvement of the family members is an effective approach in person
centered care plan ( Dewar & Nolan, 2013). This helps to decrease errors in the therapy plan.
If the family members of Ruth Stoll were present at the time of sample collection, such
manual error might have been prevented as reported by the coroner.
Conclusion
Thus from the above case study analysis, it can be concluded that nursing
professionals must practice in safe and competent manner in order to avoid the chances of
unwanted casualties or loss of life. The analysis of the case study also helped me to
understand that it is important for the healthcare professionals to include the family members

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of the heart patients or the aged care patient in every process of the care plan. This is because,
the heart patients who are elderly, remain so anxious and pre-occupied in their thoughts that
they fail to determine what is best for them. Involvement of the family members will promote
safe practice and avoidance of casualties.
Action Plan
My action plan will be practice in a safe and competent manner even under huge
work-pressure. For this I will make use of the electronic documentation system so that the
manual errors can be avoided. Redley and Botti (2013) is of the opinion that electronic
tabulation of medical data helps to reduce the chances of manual error. I will also try to
include the patient’s family member while taking any determining steps in the therapy plan
Suppose in this case, I would have re-verified the blood group with the family members of
Ruth Stoll in order to avoid complications.

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Reflection
ABC News. (2003). Coroner recommends changes after blood mix-up patient death. Access
date: 10th August 2018. Retrieved from:
http://www.abc.net.au/news/2003-03-12/coroner-recommends-changes-after-blood-
mix-up/1816102
Australian Commission on Safety and Quality in Health Care. (2017). National Safety and
Quality Health Service Standards. Access date: 10th August 2018. Retrieved from:
https://www.safetyandquality.gov.au/wp-content/uploads/2017/12/National-Safety-
and-Quality-Health-Service-Standards-second-edition.pdf
Brännström, M., & Boman, K. (2014). Effects of person‐centred and integrated chronic heart
failure and palliative home care. PREFER: a randomized controlled study. European
journal of heart failure, 16(10), 1142-1151. https://doi.org/10.1002/ejhf.151
Cowan, P. A., & Hetherington, E. M. (2013). Individual and family life transitions: A
proposal for a new definition. In Family transitions (pp. 15-42). Routledge. Retrieved
from:
https://www.taylorfrancis.com/books/e/9781134760909/chapters/10.4324%2F978020
3772393-6
Dewar, B., & Nolan, M. (2013). Caring about caring: developing a model to implement
compassionate relationship centred care in an older people care setting. International
Journal of Nursing Studies, 50(9), 1247-1258.
https://doi.org/10.1016/j.ijnurstu.2013.01.008

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Griffith, R. (2016). Repurcussions of negligence in community nursing practice. British
journal of community nursing, 21(3), 155-158.
https://doi.org/10.12968/bjcn.2016.21.3.155
Melvin, C. S. (2015). Historical review in understanding burnout, professional compassion
fatigue, and secondary traumatic stress disorder from a hospice and palliative nursing
perspective. Journal of Hospice & Palliative Nursing, 17(1), 66-72. doi:
10.1097/NJH.0000000000000126
Nursing and Midwifery Board of Australia. (2017). Code of Professional Conduct for Nurses
in Australia. Access date: 10th August 2018. Retrieved from:
http://www.nursingmidwiferyboard.gov.au/
Redley, B., & Botti, M. (2013). Reported medication errors after introducing an electronic
medication management system. Journal of clinical nursing, 22(3-4), 579-589.
https://doi.org/10.1111/j.1365-2702.2012.04326.x
Sahu, S., & Hemlata, A. V. (2014). Adverse events related to blood transfusion. Indian
journal of anaesthesia, 58(5), 543. doi: 10.4103/0019-5049.144650