Reflection on a Critical Incident

This reflection evaluates a critical incident involving wrong labeling in healthcare facilities resulting in incompatible blood transfusion and the death of a patient. The consequences, implications for future nursing practice, and an action plan are discussed. The incident highlights the importance of patient safety and the need for continuous improvement in healthcare practices. Subject: Healthcare, Course Code: N/A, Course Name: N/A, College/University: N/A

Running head: REFLECTION ON A CRITICAL INCIDENT 1
Reflection on a Critical Incident
Student’s Name
Institutional Affiliation
Date

REFLECTION ON A CRITICAL INCIDENT 2
Introduction
Throughout the assignment, am going to evaluate a critical incident concerning the
negative impacts associated with wrong labeling within the healthcare facilities. Reflection on
critical incidents has a vital role in clinical practice since it acts as a valuable learning tool
for physicians (thesis). Blood transfusion is the critical incident that is being examine in this
assignment. Gibbs (1988) cycle is made up of six stages. The cycle begins with situation
description, analysis of the feeling, followed by evaluation of the experience identification and
discussion of the knowledge acquired from the incident and the final development of the action
plan.
Critical Incident: Incompatible Blood Transfusion
Description of the Situation
I was shocked to discover that the medics wrongly labeled tubes used in carrying blood
for transfusion leading to the death of Miss Stoll. The patient went for surgery at Wakefield
Hospital. However, due to difficulty during the operation, there was excess bleeding forcing the
doctor to add Miss Stoll six units of blood through transfusion. Nonetheless, it was realized that
incompatible blood transfusion due to negligence of physicians. Wrong labeling of the sample
within the hospitals is alarming especially with all the control guidelines as well as a protocol
that is often put in place. Surgical timeout which refers to planned paused to review significant
aspects within the operating room play a crucial role in minimizing medical errors (Seiden, &
Barach, 2016). According to Australian Nursing Council (2003) the practice requires healthcare
providers to explore their actions as well as feelings through examining evidenced-based
literature, hence helping to bridge the gap that exists between theoretical and practical work.
Mislabeling of at the Veterinary Science and the Clinpath Laboratories has made me feel

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intimidated and sad because I cannot believe such an incident can happen to experienced and
knowledgeable doctors of that status. According to ABC news 2003, Miss Stoll was blood group
O, transferring blood group A to her during the blood after the surgery was very detrimental
(Middleton, Sarah, and Michael Buist, 2013). However, this is against competency standards for
the nursing practitioners NP that defines the scope and capabilities. Since blood group A and O
are incompatible, it resulted in a multi-system failure known as massive acute haemolysis,
thereby causing the death of Miss Stoll.
Feelings
The incidents on wrong labeling of blood sample leading to incompatible blood
transfusion have made me sad since it led to the death of Miss Stoll even though such incidences
can be managed and prevented (Cashin, et al., 2015). Therefore, reflecting on an incident enables
physicians to learn essential lessons from what worked and that which did not materialize
Evaluation of the Consequences
According to Nursing & Midwifery Board of South Australia., Australian Nursing and
Midwifery Council., & Nurses Board of South Australia (2013), labeling errors on samples have
potentials of causing severe consequences for patients and family members. Wrongly labeling
has made confidence that the patient used to have on the safety system undermined. Severe
health outcome such as death due to the incompatibility of blood transfusion caused by sampling
errors has brought a lot of pain to the family (Thomas, Chaperon, & Federation, 2013).
Therefore, through this happening, Miss Stoll family such as her sister-in-law Mrs. Roma Stoll
experienced a lot of trauma and suffering after the death. Additionally, Miss Stoll death has
negative impacts since other patients will perceive blood transfusion as a health hazard hence
failing to go for those services. There are no well outlined factors that predict the outcome after

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ABO incompatible transfusion is carried out (Ahrens, Pruss, Kiesewetter, & Salama, 2015).
Family members also spend a lot of resources in correcting the incompatible blood transferred to
their patient, treatment, and burial of the diseased.
Analysis of the Implication for Future Nursing Practice
Physicians have the responsibility of safeguarding as well as promoting the interest of
patients (Australian Commission for Safety and Quality in Health Care, 2012). Healthcare
providers must ensure that their knowledge, competencies skills and competencies
commensurate with the duty being undertaken. Therefore, nurses are associated with
improvement of specialty and competency standards according to Australian NMBA
(Edmonds, Cashin, & Heartfield, 2016). Wrong labeling often leads to ABO-incompatible blood
transfusion resulting in the death of patients. Therefore, future nursing practiced will be based on
appropriately policies, feedbacks and teamwork work (Lawton, & Parker, 2013). Additionally,
the critical incident will lead to significant discovery through transformative learning that will
help to reduce the label errors happening in the healthcare facilities. Moreover, I believed critical
incidents would lead to quality nursing care and competency of the nursing leading to decrease
of death caused by wrong labeling.
Knowledge Gained from this Incident
I have learned that all patients who are undergoing blood transfusion must wear a risk-
assessed equivalent or identity band. According to NMBA Registered Nurse Standards for
Practice, individual receiving health care are supposed to be guaranteed safe, competence and
evidenced based care resulting to ideal outcomes (Nagle, et la., 2017). Additionally, I have
learned that collection, as well as the labeling of sample tubes, should be undertaken through a
continuous process that involves one patient and one staff member. Additionally, I have realized

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that sample tubes should only have a minimum of one client identifier such as date, sampling
time as well as the identity of the individual taking the sample. Finally, I have realized that
samples that do not meet the above minimum demands should be rejected.
Action Plan
My future in nursing practice will be based on becoming proactive in case I feel that there
is a potential risk to client confidentiality since. I will employ back to basic approach within the
first annual short to reduce errors (Bolton‐Maggs, & Cohen, 2013). Consequently, I will not
compete or assume that other staff members will always act professionally every time.
Moreover, I will ever undertake reflective exercise through the use of the model that Gibbs
(1988) proposed. As a healthcare trainee, I am focusing on ensuring that I consistently
implement the principles as well as the values as set by the HCPC. International Council for
Nurses requires that nurses be licensed since it contributes to patient protection as well as
outcomes through enforcement of standards of practice (Ossenberg, Henderson, & Dalton,
2015).
Conclusion
Having seen the dangers and distress that is caused by wrong labelling to both patient and
their families, I now understand the significance of being attending and confidence is the same
situation were to come up in the future. I know realize that human beings are prone to error and
cannot be perfect. However, after witnessing the fatal outcome of incompatible blood
transfusion, I suggest that similar identification should be applied not only to the labelling of the
blood sample but also during the test request, patient identification sample collection, and
transportation.

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References
Ahrens, N., Pruss, A., Kiesewetter, H., & Salama, A. (2015). Failure of bedside ABO testing is
still the most common cause of incorrect blood transfusion in the Barcode
era. Transfusion and apheresis science, 33(1), 25-29.
Australian Commission for Safety and Quality in Health Care. (2012). Quick-start guide to the
implementating national safety and quality health service standard 9: Recognising and
responding to clinical deterioration in acute health care. Darlinghurst, N.S.W: Australian
Commission for Safety and Quality in Health Care. (NMBA)
Australian Nursing Council. (2003). Code of professional conduct for nurses in Australia.
Dickson, ACT: The Council (NMBA)
Bolton‐Maggs, P. H., & Cohen, H. (2013). Serious Hazards of Transfusion (SHOT)
haemovigilance and progress is improving transfusion safety. British journal of
haematology, 163(3), 303-314.
Cashin, A., Buckley, T., Donoghue, J., Heartfield, M., Bryce, J., Cox, D., ... & Dunn, S. V.
(2015). Development of the nurse practitioner standards for practice Australia. Policy,
Politics, & Nursing Practice, 16(1-2), 27-37.
Edmonds, L., Cashin, A., & Heartfield, M. (2016). Comparison of Australian specialty nurse
standards with registered nurse standards. International nursing review, 63(2), 162-179.
Lawton, R., & Parker, D. (2013). Barriers to incident reporting in a healthcare system. BMJ
Quality & Safety, 11(1), 15-18.

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Middleton, Sarah, and Michael Buist. "The coronial reporting of medical-setting deaths: a legal
analysis of the variation in Australian jurisdictions." Melb. UL Rev. 37 (2013): 699.
(ABC new 2003)
Nagle, C., Heartfield, M., McDonald, S., Morrow, J., Kruger, G., Bryce, J., Birks, M., ...
Hartney, N. (2017). A necessary practice parameter: Nursing and Midwifery Board of
Australia Midwife standards for practice. (Women and birth. (NMBA)
Nursing & Midwifery Board of South Australia., Australian Nursing and Midwifery Council., &
Nurses Board of South Australia. (2013). NmbSA Professional codes, standards,
guidelines and tools for nurses & midwives in South Australia. Adelaide, S. Aust:
Nursing and Midwifery Board South Australia (australia safety and quality standard)
Ossenberg, C., Henderson, A., & Dalton, M. (2015). Determining attainment of nursing
standards: the use of behavioural cues to enhance clarity and transparency in student
clinical assessment. Nurse education today, 35(1), 12-15.
Seiden, S. C., & Barach, P. (2016). Wrong-side/wrong-site, wrong-procedure, and wrong-patient
adverse events: are they preventable?. Archives of surgery, 141(9), 931-939.
Thomas, I., Chaperon, Y., & Federation, A. N. (2013). Submission to the health workforce
Australia consultation paper on nursing workforce retention and productivity. Australian
Nursing Federation