Nursing Incident Case Study: Fatal Consequences Of Improper Handling Of Pathological Samples

Discussion

The nursing job role involves the management of many tasks at the same time with accurate precision, however it should be critically noted that at times due to carelessness of the nursing professionals, blunders and mishaps can take place which are irreversible and unrecoverable (Ehsani et al., 2013). This essay will focus on one such blunder that had happened due to the carelessness of a nurse in handling the pathological sample of a patient about to undergo a blood transfusion. The careless led to fatal consequences that ultimately led to the death of the patient within six days of the blood transfusion procedure. In light of the historical background of nursing practice and medical interventions, many a times due to improper handling of patients biological reports or samples or even due to delay in conveying information or conveying misinformation leads to the occurrence of fatal scenarios even death to be precise (Karavasiliadou & Athanasakis, 2014).

According to a news article published by the ABC news on 12th March, 2003, it has been made mandatory by the Coroner of South Australia to encourage the engagement of family members and friends to accompany patients affected with heart-disorders in order to avoid any discrepancy in terms of manhandling of the patient during pre-surgical procedures (Laurie & Porter, 2016). This was made mandatory after the massive accidental death of the 71- year old patient due to wrong blood transfusion during the surgery. The incident took place in Clinpath Laboratories, where two patients Mrs. Ruth Stoll and Mrs. Martha Kovendy had gone to get their blood samples tested before opting for the transfusion procedure. Mrs. Stoll had been accompanied by her sister-in-law and Mrs. Kovendy was accompanied by her husband but both the accompanists were asked to wait at the waiting are with the patients taken inside to collect the blood. While the collection of the sample was going on, the nursing professional mislabelled the blood samples. Following this during the surgery, Mrs. Stoll was monitored with the wrong blood group and as a result she died within six days of her operation (Shahrokhi et al., 2013). In relation to the incident, the Coroner in charge at that point of time, Mr. Wayne Chivell commented that it must be made mandatory that patients must be accompanied to the spot of collection with their loved ones, as it has been inferred from the incident that heart-patients are often nervous and are not able to clearly dispense the correct information about them. Also, the NSQHS, standard 2, launched an initiative of collaborating with consumers in order to ensure effective service planning, service delivery, close monitoring and evaluation of all the services combined such that it is more conveniently accessible to the consumers to avail (“Nursing and Midwifery Board of Australia – Guidelines”, 2018)

Conclusion

Using the Gibb’s reflecting cycle, after critically analysing the event I felt that it was indeed a fault on the part of the nursing professional who was entrusted with the responsibility of sample collection. Mislabelling of two different blood samples collected from different patients can lead to the generation of a fatal effect. At the same time, I feel that the Coroner’s decision was justified because, company of a loved one would not only help in reducing the nervousness of the patient but at the same time, the process would take place under the vigilance of a care provider who would double-ensure that the sample collected is addressed properly but at the same time I feel that this also exposes the lacunae of our professional ability. If the assigned job is carried out with extreme precision then there is no requirement of external factors to serve as a scrutinising tool (Dolansky et al., 2013).

The event was an unfortunate one and it elicited a negative effect on the family members of the patient, which cannot be argued upon. The family lost a valued family-member because of the carelessness of a nursing professional who is entrusted with the role of providing care and not to take away an innocent life. The family would not only be devastated by the loss of the family member but would not be able to trust the healthcare organization again.

This critical incident has helped me in accessing my capability towards being able to practice as a care-provider efficiently. It has helped me understand two most important aspects of my profession and that can be summed up into two factors, firstly to prioritize patient care and secondly to always keep in mind that what might happen because of an act of carelessness from my side (Eburn & Dovers, 2015). My profession expects me to cater to the needs of the patient and contribute efficiently in providing a decent standard of living to the patient and any casualty from my side would not only prove to fatal for the patient but would also lead to the devastation of the patient’s family for an entire life-time.

From the insight that I developed after critically going through the case of Ruth Stoll, I could decipher the facts that Mrs. Stoll had taken her last breath on 4th April, 2001 at the Wakefield hospital in Adelaide (Middleton & Buist,2013). In the year 1983, she had undergone a replacement surgery of her aortic valve but had developed ‘aneurysm’, to fix that another surgery was carried out by Doctor John Stubberfield to replace the aneurysmal aorta with a Dacron graft, however the process resulted in acute loss of blood that had to be compensated with blood transfusion and due to the mismatched ABO blood group, blood transfusion the patient died as a result of acute haemolysis.

To enhance my effectiveness, the following action-plan would be adopted by me, Objectives    Task    Success Criteria    Time-frame    Resources Skill-development    Participation in training courses    Certified completion of training    2-3 weeks    In-house training department Error-reporting    Being able to report errors voluntarily using organizational system    Being able to report errors independently    4 weeks    Supervision under seniors and trainers Be able to identify Joint commission’s national safety goals    Be able to identify patient’s correctly and maintain records efficiently    Positive feedback from trainers and supervisors   32 weeks    Guidance of supervisors and conceptual knowledge. Identify patient-safety risks    Be able to concentrate while collecting samples or use medicines safely    Positive feedback from patients.

Conclusion:

Therefore to conclude, I would like to state that with strict adherence to the action plan that I have set for myself I would be able to avoid any critical medical error while carrying out an intervention. At the same time it should also be noted that healthcare professionals are care providers on who the responsibility of maintenance of the quality life of the patients depend, hence it is inevitable for them to be extra cautious while performing their duty.

References:

Dolansky, M. A., Druschel, K., Helba, M., & Courtney, K. (2013). Nursing student medication errors: a case study using root cause analysis. Journal of professional nursing, 29(2), 102-108.

Eburn, M., & Dovers, S. (2015). Learning Lessons from Disasters: Alternatives to Royal Commissions and Other Quasi?Judicial Inquiries. Australian Journal of Public Administration, 74(4), 495-508.

Ehsani, S. R., Cheraghi, M. A., Nejati, A., Salari, A., Esmaeilpoor, A. H., & Nejad, E. M. (2013). Medication errors of nurses in the emergency department. Journal of medical ethics and history of medicine, 6.

Karavasiliadou, S., & Athanasakis, E. (2014). An inside look into the factors contributing to medication errors in the clinical nursing practice. Health Science Journal, 8(1).

Laurie, G. T., & Porter, G. (2016). Mason and McCall Smith’s law and medical ethics. Oxford University Press. Pp 135-140

Nursing and Midwifery Board of Australia – Guidelines. (2018). Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx

Middleton, S., & Buist, M. (2013). The coronial reporting of medical-setting deaths: a legal analysis of the variation in Australian jurisdictions. Melb. UL Rev., 37, 699.

Paterson, C., & Chapman, J. (2013). Enhancing skills of critical reflection to evidence learning in professional practice. Physical Therapy in Sport, 14(3), 133-138.

Shahrokhi, A., Ebrahimpour, F., & Ghodousi, A. (2013). Factors effective on medication errors: A nursing view. Journal of research in pharmacy practice, 2(1), 18.