HLT54115 Nursing
Question:
Prior to her heart surgery Ruth Stoll was required to go to Clinpath Laboratories to give a sample of blood so it could be tested in case she needed a transfusion.
She was there with another patient Martha Kovendy.
The one nurse in turn took blood from both women but, as the coroner found, she mislabelled the two test tubes.
Ms Stoll did require a transfusion during her operation but received the wrong blood. She died six days later.
Coroner Wayne Chivell recommended carers should be present at these pre-operative procedures.
Ms Stoll’s sister-in-law and Ms Kovendy’s husband remained outside in the waiting area while the blood samples were
taken.
The coroner said heart patients are often very anxious and do not communicate well. The presence of carers would
minimise the risk of error or confusion.
Answer:
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 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.
Analysis
The main implications of the incident over my nursing practice, I will be more diligent and focused while handling the patient’s sample of reports. According to Griffith (2016) causality occurring from the nursing error, creates huge repercussion over the nursing professionals which further affects the overall quality of care of other patients. Melvin (2015) is of the opinion that in order to avoid manual errors in the nursing profession, the nursing professionals are required to be focused even while handling huge workload and compassion fatigue. This again goes with the standard 1 of NMBA code of conduct which encourage the nursing professionals to practice in safe and competent manner. The implication of the critical incident as discussed above are also guided by the standard 2 of National Safety and Quality Health Service Standards (NSQHS), which promotes partnering and consumers. This signifies that strategies are required to be generated that promotes person-centered health care system that includes both the patients and their carers in the decision making process (Australian Commission on Safety and Quality in Health Care, 2017). In case of Ruth Stoll, the person centered care approach will include her family members. This is because, Brännström and Boman (2014) highlighted that in aged care or caring aged patients with cardiac patients, involvement of the family members is an effective approach in person centered care plan ( Dewar & Nolan, 2013). This helps to decrease errors in the therapy plan. If the family members of Ruth Stoll were present at the time of sample collection, such manual error might have been prevented as reported by the coroner.
Conclusion:
Thus from the above case study analysis, it can be concluded that nursing professionals must practice in safe and competent manner in order to avoid the chances of unwanted casualties or loss of life. The analysis of the case study also helped me to understand that it is important for the healthcare professionals to include the family members of the heart patients or the aged care patient in every process of the care plan. This is because, the heart patients who are elderly, remain so anxious and pre-occupied in their thoughts that they fail to determine what is best for them. Involvement of the family members will promote safe practice and avoidance of casualties.
Action Plan
My action plan will be practice in a safe and competent manner even under huge work-pressure. For this I will make use of the electronic documentation system so that the manual errors can be avoided. Redley and Botti (2013) is of the opinion that electronic tabulation of medical data helps to reduce the chances of manual error. I will also try to include the patient’s family member while taking any determining steps in the therapy plan Suppose in this case, I would have re-verified the blood group with the family members of Ruth Stoll in order to avoid complications.
Reflection:
ABC News. (2003). Coroner recommends changes after blood mix-up patient death. Access date: 10th August 2018. Retrieved from: https://www.abc.net.au/news/2003-03-12/coroner-recommends-changes-after-blood-mix-up/1816102
Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards. Access date: 10th August 2018. Retrieved from: https://www.safetyandquality.gov.au/wp-content/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf
Brännström, M., & Boman, K. (2014). Effects of person?centred and integrated chronic heart failure and palliative home care. PREFER: a randomized controlled study. European journal of heart failure, 16(10), 1142-1151. https://doi.org/10.1002/ejhf.151
Cowan, P. A., & Hetherington, E. M. (2013). Individual and family life transitions: A proposal for a new definition. In Family transitions (pp. 15-42). Routledge. Retrieved from: https://www.taylorfrancis.com/books/e/9781134760909/chapters/10.4324%2F9780203772393-6
Dewar, B., & Nolan, M. (2013). Caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting. International Journal of Nursing Studies, 50(9), 1247-1258. https://doi.org/10.1016/j.ijnurstu.2013.01.008
Griffith, R. (2016). Repurcussions of negligence in community nursing practice. British journal of community nursing, 21(3), 155-158. https://doi.org/10.12968/bjcn.2016.21.3.155
Melvin, C. S. (2015). Historical review in understanding burnout, professional compassion fatigue, and secondary traumatic stress disorder from a hospice and palliative nursing perspective. Journal of Hospice & Palliative Nursing, 17(1), 66-72. doi: 10.1097/NJH.0000000000000126
Nursing and Midwifery Board of Australia. (2017). Code of Professional Conduct for Nurses in Australia. Access date: 10th August 2018. Retrieved from: https://www.nursingmidwiferyboard.gov.au/
Redley, B., & Botti, M. (2013). Reported medication errors after introducing an electronic medication management system. Journal of clinical nursing, 22(3-4), 579-589. https://doi.org/10.1111/j.1365-2702.2012.04326.x
Sahu, S., & Hemlata, A. V. (2014). Adverse events related to blood transfusion. Indian journal of anaesthesia, 58(5), 543. doi: 10.4103/0019-5049.144650
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