Nursing Reflection on Blood Transfusion Reaction Case Study

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

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NURSING REFLECTION
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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NURSING REFLECTION
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.