Table of Contents
- Action Plan
In the nursing calling, many occasions of suit can happen, despite healthcare professionals’ in giving quality care to their patients. In this task undertaking, I would like to consider reflecting on an event that has occurred amid my practices using the Model of Reflection by Gibbs, G. (1988). Blood transfusions is a typical piece of nursing practice and a lifesaving intervention, however a territory of training with frequent blunders.
During my second year clinical practice in High Dependency Unit, one of my patients, Mr S was admitted for lower GI bleeding and had episodes of melena stool. He was admitted during the night shift, upon admission to my ward, blood tests was done and the result showed his haemoglobin was 7g/dL. Patient was hemodynamically unstable with low blood pressure and presented pale. Emergency colonoscopy was done bedside and patient was intervened with blood transfusions. I took over the patient in the morning. Routinely after receiving report, I and the night staff made a bedside assessment of the patient together. When I was checking on the blood bag that was hooked up on the drip stand prior passing over to me, I noticed that it has a different patient’s name on the blood bag label.
Eventually patient developed fever, chills, flank pain and shortness of breath. Patient deteriorated further and was resuscitated before passing on later on my shift. Later investigations was carried out and revealed that the staff collected the product overlooked the name on the blood bag, brought it to the department, had another staff to counter check who also failed to spot and carried 2on hooking on the patient. They both then concurred to have committed the oversight and finally was restricted from practicing.
During the event, I had a number of feelings. I felt sympathy for the patient who came into the hospital believing that we could save his life, but it turned out to be a tragedy. When the patient collapsed before my eyes, I automatically called for help and assisted in reviving the patient and did all I can, at the back of my mind thinking that this could be prevented. I then explained to my nurse manager who was on duty at that time of the incident and noted it was a technical error. She was vanquished and stunned, and it made me question myself how could this situation been avoided. This event took me back to doing a lot of researches on the legal issues that happened around the world. It is miserable to know that it took many lives.
The occurrence was to a great degree challenging for the whole High Dependency Unit and me. From this incident, I have learned to act assertively and to be more vigilant in order to protect patients’ well-being. Blood transfusion procedure will save and enhance patients’ lives however careful thought should run to the associated dangers. Nurses should have the abilities and be extra cautious on patients receiving blood components. It is vital for nurses to know the right and safe (Oldham J, Sinclair L, Henry C, 2009). The procedure isn’t a risk, however foremost errors occur due to human negligence.
Being able to relate to this situation, it increased my ability to deal with the situation more effectively. Transfusing correct blood product is a convoluted, multi stepped procedure involving many parties, which includes physicians, nurses, lab technicians and porters. Problems related with blood transfusions and blood products are to a great extent associated with human error and inability to adhere with policies. In spite of the fact of getting a viral transmission through blood products and other blood components are very narrow, mistransfusions, where blood units are mistakenly transfused to a non-assigned receiver, remains the most prevalent type of lapse (A. Ohsaka, 2009). For instances, blood tests are inaccurately or not entirely labelled, or inadequate security check prior transfusions.
The Gibbs model of reflection undoubtedly allowed me to confess the event and explore my feelings towards this event. Colin Paterson and Judith Chapman (2013), stated that reflection is an important part of learning from experience, a centre for development and competency maintenance throughout the practitioner’s life. As a registered nurse, I hold responsibilities and be in control of my actions and abide to the hospitals policies and standard of practice to provide an optimum care for my patients. From this event I have learned.
With the increasing stress and effectiveness in the health care practice, how diligently we carry out procedures to safe patients’ life is crucial. In future, after double checking the blood products and the doctor’s order by two nurses, we should scan the barcode on the blood products against patient’s wrist tag before commencing the transfusion. By using this verification method, it will reduce the rate of such incidents. Besides the compatibility check, the basic thing to do prior any transfusion is a bedside check with another registered nurse on the correct blood product intended for the correct patient. It gives a final opportunity to intrude on a misguided blood components. There is also an essential need for staffs to be educated on reducing risk of blood transfusion, being updated on the most recent safety guidelines, interventions and decision making if the situation arose.