Coroner's Inquest: Critical Reflection on a Nursing Event

This essay critically evaluates a nursing-related event, specifically a patient's death due to a blood transfusion error, as presented in a coroner's inquest. Utilizing Gibbs' reflective cycle, the student explores the incident's description, personal feelings, and evaluation of the event, highlighting the impact of mislabeled blood samples. The analysis delves into the responsibilities of nurses in ensuring patient safety and adhering to the NMBA Standards for Practice and ACQSHC guidelines. The conclusion emphasizes the importance of accurate specimen handling and the role of nurses as gatekeepers against medical errors. The essay outlines an action plan for future practice, emphasizing vigilance, double-checking procedures, and patient support to prevent similar incidents.

Running head: CORONER’S INQUEST
Coroner’s inquest
Name of the Student
Name of the University
Author note

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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. The NMBA 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While the blood samples were withdrawn, her husband and sister-in-law were outside and no one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

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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 practice mentions 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).

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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
have the responsibility to ensure patient safety during specimen collection and labelling
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 in ACQSHC that covers medication safety and responding to the clinical deterioration.
These standards provide a consistent and nationally statement about standards of care that
consumers can expect from the healthcare organizations and the delivery of services
(safetyandquality.gov.au 2018).
The Standard 2: Partnering with Consumers guides 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
these systematic and standardized processes, nurses can improve medical safety through
prevention of such medical error incidents. In addition, to avoid such critical situations in the
future, ACQSHC guides 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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and have serious consequences for patient as well as the healthcare organization. The incident
added to my existing knowledge that medical errors are inevitable and 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 the ACQSHC consensus quality
standards and Conduct Statement 1 under NMBA code of professional conduct where it states
that nurses should be aware of their undertaking activities within their nursing practice that
compromise patient safety (nursingmidwiferyboard.gov.au 2018).

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References
abc.net.au. (2018). Coroner recommends changes after blood mix-up patient death. Retrieved
from http://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). Retrieved from
http://www.nursingmidwiferyboard.gov.au/documents/default.aspx?
record=WD10%2F1353&dbid=AP&chksum=Ac7KxRPDt289C5Bx%2Ff4q3Q%3D
%3D
nursingmidwiferyboard.gov.au. (2018). Retrieved from
http://www.nursingmidwiferyboard.gov.au/documents/default.aspx?
record=WD16%2F19520&dbid=AP&chksum=ga2EcHDo5OKLhC%2BTVHZh2Q%3D
%3D
safetyandquality.gov.au. (2018). National Safety and Quality Health Service Standard 2:
Partnering with Consumers | Safety and Quality. Retrieved from
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). Retrieved from https://www.safetyandquality.gov.au/wp-
content/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-second-
edition.pdf

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Van Leeuwen, A. M., & Bladh, M. L. (2017). Davis's comprehensive handbook of laboratory &
diagnostic tests with nursing implications. FA Davis. Retrieved from:
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