Critical Reflection of a Wrong Blood Transfusion Scenario

Running head: WRONG BLOOD TRANSFUSION 1
Critical Reflection of a Wrong Blood Transfusion Scenario
Name
Institutional Affiliation

WRONG BLOOD TRANSFUSION 2
By human nature, nursing errors in clinical settings are inevitable. The adverse effects of
such errors, however, varies in intensity depending on the error that has occurred. Mislabeling of
blood samples is an example of nursing errors that result in the transfusion of the wrong blood to
a patient should need for transfusion arise. When determining the type of blood to be transfused
into a patient, doctors use previously collected samples for reference. If the samples had been
mistakenly labelled, however, it goes without saying that the patient will receive a wrong blood
transfusion. If the aforementioned occurs, the consequences are lethal to the entire circulation
system of the patient and could easily result to death. Consequently, the outcomes of wrong
blood transfusion are distressful to a patient’s relatives and/or carers. This essay is therefore a
critical reflection of a wrong blood transfusion scenario and the possible courses of action that
could be implemented in the nursing practice to curtail re-occurrence of the same.
Ms. Ruth Stoll had been hospitalized to undergo a heart surgical operation (ABC-News,
2003). Before she could proceed to the theatre, however, she was required to visit Clinpath
laboratories. Here, a sample of her blood was taken for testing and to be used as the reference for
sourcing the right blood type in case she required a transfusion during her surgery. While in the
laboratory, nevertheless, she encountered another patient, Martha Kovendy who was also there to
give her blood sample. There was only one nurse on duty who took blood from the two ladies but
mistakenly interchanged labels for the two test tubes with samples from the two ladies. During
the entire sample collection process, Ms. Kovendy’s husband and Ms. Stoll’s sister in law sat in
the waiting area outside the laboratory facility. During the operation, it became necessary for Ms.
Stoll to receive blood through transfusion and was subsequently transfused with the wrong
blood. The results were catastrophic as she died six days later (ABC-News, 2003).

WRONG BLOOD TRANSFUSION 3
This incident has inflicted sad and remorseful feelings on me. In my endeavors and
aspirations to become a registered nurse, it is definitely disheartening to learn that some of the
errors that could arise out of my actions could be such devastating. It is also sad to learn that the
patient had visited the medical facility in search of treatment for more complicated issue only to
pass on because of an issue that could be highly avoided. I, consequently, maintain a strong stand
a belief that no patient should meet their death as a result of errors committed by clinical
personnel. On the healthcare consumer’s side, this incident definitely resulted in numerous
negative implications. It goes without saying that the event was traumatizing for Ms. Stoll’s
sister-in-law and all other close relatives (Berlot, Delooz, & Gullo, 2012). They are all bound to
lose faith in the clinical facilities’ undertakings and it could take them some time before
recovery. Successively, they are most likely to develop a strong negative attitude towards the
facility. They would therefore not seek medical help from it in the near future in case of illness
but would resolve to visit alternative medical facilities. Lastly, consumers are likely to develop
feelings of hatred towards the specific staff involved in this incident.
This incident has directly implicated my future practice as a registered nurse in several
ways. Most importantly, it will help me research more on the nursing interventions that I will
apply during my practice to curb the occurrence of such an incident out of my actions. Acute
hemolytic transfusion reaction occurs after a wrong blood transfusion (Butterfield, 2015). There
are certain symptoms that are indicators of a wrong blood transfusion. Respiratory distress,
chills, fever, pain, and hyper-/hypotension are such examples that I should be well conversant
with (Colledge & Boskey, 2017). Upon sighting any of these symptoms, the transfusion should
be terminated immediately. A clerical check should then be conducted immediately to confirm
whether it was the right unit for the patient. During my practice, it will be my duty to ensure that