Critical Evaluation of Patient Death After Blood-Mixing Incident
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This assignment evaluates the patient death after blood-mixing incident through reflective practice and Gibb’s reflection cycle. It discusses the importance of accurate specimen withdrawing and labelling, NMBA Standards for Practice, and ACQSHC consensus quality standards.
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Running head: CORONER’S INQUEST Coroner’s inquest Name of the Student Name of the University Author note
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1 CORONER’S INQUEST The following assignment focuses on the critical evaluation of a nursing related event, “patient death after blood-mixing” through the use of reflective practice, Gibb’s reflection cycle. In the event, the patient received wrong blood group and that resulted in her death. This event is an example of severe medical error where the blood test sample was mislabelled.ACQSHC (Australian Commission for Quality and Safety in Healthcare)recommends that public should be protected from harm and healthcare professionals and systems are expected to meet the standards of patient safety and quality while delivering care. TheNMBA Standards for Practice will also be discussed that outlines nursing requirements in order to provide safe and highest quality care. Description The incident took place in 2003 when Ruth Sophie Stoll, a 71-year-old patient died after she received wrong blood type during a transfusion. Prior to heart surgery, the patient was taken to the Clinpath Laboratories for giving a sample of blood to test in case of transfusion. Another patient, Martha Kovendy was also present along with her. The nurse took blood from both women, however as per coroner’s report, she mislabelled the test tubes. She required transfusion during the surgery, however received wrong blood group leading to her death after six days. While the blood samples were withdrawn, her husband and sister-in-law were outside and no one to accompany to the pre-operative procedure (abc.net.au 2018). Feelings The incident was depressing and on being informed about the patient’s death, my initial feelings were of horror and complete disbelief. I was literally confused that the nurse did not check the name and blood sample while labelling. I felt very embarrassed and upset that after
2 CORONER’S INQUEST qualifying as a nurse, how anyone can make such a mistake. I felt ashamed and shocked that how can the nurse be distracted during such a crucial task. The nurse not only failed in her profession but also patient too. I was also worried about the potential effects of blood mixing that can cause severe repercussions for the patient. Evaluation The biggest disadvantage of this incident is that it led to the unfortunate death of the patient due to blood mixing. On a personal level, I feel that it is important to enhance one’s clinical practice so that no harm is caused to the patient. This incident has highlighted the fact that there is need of strict vigilance prior to surgery procedures as heart patients are often anxious and unable to communicate well (Alanazi, 2014). The presence of family members or carers would have minimized the mislabelling of the two test tubes before transfusion. I am well aware and informed that one should not be complacent during pre-operative procedures and blood sampling. The above incident has serious consequences for the patient and her family members. Specimen mislabelling resulted in death of the patient that was otherwise preventable. Nurses have the responsibility to coordinate, determine and provide quality and safety nursing. RNs should be accountable and responsible for their actions and nursing practice as a whole. Standard 6 under NMBA, RN standards for practicementions that appropriate, safe and responsive quality of nursing practice should be provided by nurses. They should practice in accordance with the relevant standards, guidelines and regulation so that nurses deliver effective and safe services in their profession and use their skills (nursingmidwiferyboard.gov.au 2018).
3 CORONER’S INQUEST Analysis Specimen labelling error is a common form of medical error that can jeopardize safety of patient being a critical component of accurate and effective patient identification. Timely and accurate labelling of specimens is important for ensuring patient safety. I analysed that nurses havetheresponsibilityto ensurepatientsafetyduringspecimencollectionandlabelling procedure (Van Leeuwen & Bladh, 2017). To prevent such medical errors in the future, nurses should label the test tube first, then withdraw the blood and handle one patient at a time. For my future nursing practice, I will adhere to comprehensive and detailed standards and procedures are outlined inACQSHCthat covers medication safety and responding to the clinical deterioration. These standards provide a consistent and nationally statement about standards of care that consumerscanexpectfromthehealthcareorganizationsandthedeliveryofservices (safetyandquality.gov.au 2018). The Standard 2: Partnering with Consumersguides nursing practice and outlines strategies and systems that create a person-centred approach by ensuring that patients are considered to be partners in the provision of care and expect quality health care. By adhering to thesesystematicandstandardizedprocesses,nursescanimprovemedicalsafetythrough prevention of such medical error incidents. In addition, to avoid such critical situations in the future,ACQSHCguides nurses that there should be clear and open communication between patients and clinicians, carers and families in their own care (safetyandquality.gov.au 2018). Conclusion From the incident, it can be concluded that accurate specimen withdrawing and labelling is a vital part of nursing role. Mislabelling can result in severe injury or even death of the patient
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4 CORONER’S INQUEST and have serious consequences for patient as well as the healthcare organization. The incident added to my existing knowledge that medical errors are inevitableand nurses have the responsibility to build a safe and quality healthcare system in the process of care ensuring patient safety and protecting them from any harm. Nurses act as “gatekeepers” in the prevention of medical errors and they should minimize distractions throughout a particular process to ensure patient safety. Action Plan From the incident, I have learnt that I will not be distracted or anxious during the process of specimen collection and labelling to avoid any kind of medical error. I will double check the patient’s name with the specimen and handle one patient at a time. I will also accompany my patient or delegate a carer during pre-operative procedures as patients panic and often anxious and as a result, they are unable to communicate. I will adhere to theACQSHCconsensus quality standards andConduct Statement 1 under NMBA code of professional conductwhere it states that nurses should be aware of their undertaking activities within their nursing practice that compromise patient safety (nursingmidwiferyboard.gov.au 2018).
5 CORONER’S INQUEST References abc.net.au. (2018). Coroner recommends changes after blood mix-up patient death. Retrieved fromhttp://www.abc.net.au/news/2003-03-12/coroner-recommends-changes-after-blood- mix-up/1816102 Alanazi, A. A. (2014). Reducing anxiety in preoperative patients: a systematic review.British Journal of Nursing,23(7), 387-393. Doi:https://doi.org/10.12968/bjon.2014.23.7.387 nursingmidwiferyboard.gov.au.(2018).Retrievedfrom http://www.nursingmidwiferyboard.gov.au/documents/default.aspx? record=WD10%2F1353&dbid=AP&chksum=Ac7KxRPDt289C5Bx%2Ff4q3Q%3D %3D nursingmidwiferyboard.gov.au.(2018).Retrievedfrom http://www.nursingmidwiferyboard.gov.au/documents/default.aspx? record=WD16%2F19520&dbid=AP&chksum=ga2EcHDo5OKLhC%2BTVHZh2Q%3D %3D safetyandquality.gov.au.(2018).NationalSafetyandQualityHealthServiceStandard2: PartneringwithConsumers|SafetyandQuality.Retrievedfrom https://www.safetyandquality.gov.au/our-work/patient-and-consumer-centred-care/ national-safety-and-quality-health-service-standard-2-partnering-with-consumers/ safetyandquality.gov.au.(2018).Retrievedfromhttps://www.safetyandquality.gov.au/wp- content/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-second- edition.pdf
6 CORONER’S INQUEST Van Leeuwen, A. M., & Bladh, M. L. (2017).Davis's comprehensive handbook of laboratory & diagnostictestswithnursingimplications.FADavis.Retrievedfrom: https://books.google.co.in/books? hl=en&lr=&id=Nn7bDQAAQBAJ&oi=fnd&pg=PR1&dq=specimen+collection+and+lab elling+procedure+nursing+responsibility&ots=dGOO4slm0s&sig=dJOJizqHAhZaDgQA Ky2Oqro_Kqk#v=onepage&q=specimen%20collection%20and%20labelling %20procedure%20nursing%20responsibility&f=false