The aim of this essay is for students to critically reflect on a nursing related event reported in the media and, using the NSQHS standards developed by ACQSHC (Australian Commission for Quality and Safety in Healthcare), identify what nurses might do to improve their practice and reduce the risk of a similar error. 

Introduction

Trust and respect are the key principles of a nurse-patient relationship. Critical reflection allows a nurse to discover the meaning of an experience and link various actions and events to inferences and outcomes. The present critical reflection is based on Gibbs Reflective Cycle (Gibbs, 1988). It presents the description of the case of Ruth Stoll, who died due to administration of the wrong blood type. The assignment further discusses the feelings associated with the case, the analysis, conclusion and knowledge gained, and the action plan for further learning.

Description

Ms. Ruth Stoll developed an aneurism after she had undergone a valve replacement in 1993. She was admitted to Wakefield hospital on 28 March 2001 under a cardio-thoracic surgeon to replace the aneurism by a Dacron graft. Prior to the surgery, she went to Clinpath Laboratories to give a sample of her blood for testing for arrangement of blood, which she could require during surgery. As there were two patients available during the blood collection, the nurse mislabelled the tubes. During the surgery, the right ventricle of the heart was torn causing profuse bleeding. This called for immediate blood transfusion. The bleeding was controlled and six units of blood was transfused. Ms. Stoll received the wrong blood during surgery, which led to her death six days later (ABC News, 2003). 

Feelings

After hearing about this news, I felt distressed. It was a condition, which could have been easily avoided. The negligence of the staff nurse on duty caused the death of the patient. I felt extremely sad that this kind of negligence was a breach of duty as the procedure manual prepared by the employer was not followed by the duty nurse RN Gilbert. Even after knowing the blood group of Ms. Stoll was O positive, when A positive blood was received in the operation theatre for transfusion, it was not cross checked again by the available health professionals, anesthetist or surgeon. It is well-known that transfusion of an unmatched blood causes agglutinin formation leading to a life-threatening condition. Thus, it was necessary to check the blood before transfusion (ABC News, 2003). This action made me feel angry as Ms. Stoll could have been saved with simple precautionary measures.

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