3MG042 Immunology and Transfusion Medicine | Nursing Errors

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.

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).

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 incorrect identification of blood samples is avoided on the highest priority. To curb it, I will identify a patient positively and apply the right labels to test tubes in correspondence with the patient (Dougherty & Lister, 2015). Test tubes will never land in the test tube holder prior to labeling. I will never commence collecting samples from the next patient before the previous one has been labeled and positioned in the right location to avoid possibilities of confusion (LHA-Trust-Funds, 2016).

As recommended by the South Australian coroner in Ms. Stoll’s case (ABC-News, 2003), I will ensure that relatives/carers accompany their patients to pre-operation procedures. This is in line with the Partnering with consumers Standard of the National Safety and Quality Health Service Standards (ACQSHC, 2012). By adhering to this standard, the occurrence of similar incidents will be avoided as consumers will be partners during design, planning, delivery, measurement and evaluation of systems and services. I will also avoid similar nursing errors by adhering to the Blood Management Standard. Here, I will identify risks and align strategies to ensure that patients’ own blood is optimized and conserved. I will also ensure that blood and blood products administered to the patient are appropriate and safe (Luppa & Junker, 2018). I will also observe Preventing and Controlling Healthcare-Associated Infection Standard to avoid committing any nursing error. All infections that could result from transfusion of wrong blood will, therefore, be avoided by ensuring that only the right blood is transfused. Proper management will be affected if they occur (Dougherty & Lister, 2015). Lastly, I will adhere to the four elements of the International Council of Nurses (ICN) codes of Ethics (Schober & Affara, 2009). By observing the elements, I will maintain positive and ethically-right relations between; me and my patients, myself and the nursing practice, myself and the nursing profession and lastly between me and fellow co-workers.

In conclusion, this essay has critically reflected into Ms. Stoll’s ordeal during her heart surgery. It has also brought into the limelight the nursing errors that resulted to wrong blood transfusion and subsequently, Ms. Stoll’s death. Also discussed are the various nursing interventions applicable during nursing practice to aid in curbing re-occurrence of such a mistake and other related errors. Various National Safety and Quality Health Service Standards that could be implemented to curb repetition of this vice have also been highlighted and elaborated efficiently.

References

ABC-News. (2003, March 12). Coroner recommends changes after blood mix-up patient death. ABC NEWS. Retrieved August 14, 2018, from https://www.abc.net.au/news/2003-03-12/coroner-recommends-changes-after-blood-mix-up/1816102

ACQSHC. (2012, Sept). NSQHS Standards (second edition). Retrieved from AUSTRALIAN COMMISSION ON SAFETY AND QUALITY IN HEALTH CARE: https://www.safetyandquality.gov.au/wp-content/.../NSQHS-Standards-Sept-2012.pdf

Berlot, G., Delooz, H., & Gullo, A. (2012). Trauma Operative Procedures (illustrated ed.). Springer Science & Business Media.

Butterfield, S. (2015, July). Tips on transfusion: Treating reactions and avoiding common errors. ACP Hospitalist. Retrieved August 14, 2018, from https://acphospitalist.org/archives/2015/07/transfusion-medicine.htm

Colledge, H., & Boskey, E. (2017, May 2). ABO Incompatibility Reaction. HEALTHLINE. Retrieved August 14, 2018, from https://www.healthline.com/health/abo-incompatibility

Dougherty, L., & Lister, S. (2015). The Royal Marsden Manual of Clinical Nursing Procedures (illustrated ed.). John Wiley & Sons.

LHA-Trust-Funds. (2016, August 25). How You Can Avoid Laboratory Errors. LOUISIANA HOSPITAL ASSOCIATION TRUST FUNDS. Retrieved August 14, 2018, from https://lhatrustfunds.com/how-you-can-avoid-laboratory-errors/

Luppa, P., & Junker, R. (2018). Point-of-care testing: Principles and Clinical Applications. Springer.

Schober, M., & Affara, F. (2009). International Council of Nurses: Advanced Nursing Practice. John Wiley & Sons.