Louisiana hospital association trust funds
This comes after a 71-year-old patient died when she received a transfusion of the wrong blood type.
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.
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.
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.
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
Schober, M., & Affara, F. (2009). International Council of Nurses: Advanced Nursing Practice. John Wiley & Sons.