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Critical Reflection Essay.
Critical reflection articulates professional development, encourages the re-assessment of skills and ultimately provides a reflective process that enables the practice of a nurse to provide safe and quality patient care. This essay will describe and discuss a critical incident presented in an article that entails the death of a patient due to the quality of care implemented by a registered nurse. The comprehensive description of the incident will be presented with a self reflection and an evaluation of the incident for the health consumer. Secondly, an analysis of the incident will provide a learning outcome, followed by an action plan to optimise health care delivery to prevent the repetition of future errors.
The ABC news article titled “Coroner recommends changes after blood mix up patient death” describes the mislabelling of blood samples by a registered nurse that consequently resulted in a patient’s death (ABC News, 2003). Miss Ruth Stoll, aged 71 years was scheduled for heart surgery and required pre operative blood samples. Miss Stoll was accompanied by her sister in law Mrs Roma Stoll to the Clinpath laboratories in the Wakefield Hospital Complex. A second patient Mrs Martha Kovendy was also at the laboratory accompanied by her husband. Registered Nurse (RN) Sally Gilbert was the only nurse on duty and proceeded to take their blood samples without the presence of their carers (ABC News,2003; Chivell, 2003). During this process, the blood samples were mislabelled, bagged and sent to the laboratory. Furthermore, Miss Stoll did require a blood transfusion during her surgery and received the incorrect blood samples eventuating in the decline of her health and death (Chivell, 2003). Reflecting on this article I was engaged with sadness for the loss of the patient’s life and frustrated that the death could have been avoided if safe and quality care was utilised. On evaluation it is essential that registered nurses adhere to thinking critically whilst practicing and providing safe and quality care for their patient (Nursing and Midwifery Board of Australia [NMBA], 2018; NMBA, 2016). Nurses must engage in communicating effectively and ensure documentation is correct to ensure patient safety. Furthermore, effective partnerships with patients and/or their carers can provide safer and improved quality of care for the patient as they are able to partner with the health provider to share information and assist in the optimum delivery of their health care (Australian Commission on Safety and Quality in Health, standard 2 [ACQSHC], 2017). Consequently, the implications of not adhering to the nursing standards or guidelines resulted in the death of Miss Ruth Stoll and emotional distress to the family (ABC News, 2003; Chivell, 2003). Furthermore, critically evaluating the sequential events leading to the death provides an insight as to how the quality of care can be improved by partnering up with health consumers to prov...
