Case Study A: Incorrect Administration of a Blood Product.
The entire scenario surrounds the administration of wrong blood product to a patient who had been admitted for fractured neck of femur and had been scheduled for surgery in the afternoon. Due to elevated patientâs international normalized ratio (INR) at 1.6, the patient was scheduled for one unit transfusion of fresh frozen plasma (FFP) before surgery. The whole flaw started when the MO collected and signed incomplete labeled FFP blood unit, which was allocated for another patient. Furthermore, he signed without checking the productâs details. The patient services Attendant (PSA) after being sent for clarification in the laboratory, he came and gave false information that made the nurses go ahead with transfusion process. The patient developed a mild rise in bilirubin, and the surgery was delayed so as to monitor the patient for further consequences of the transfusion therapy.
Blood transfusion remains a significant part of everydayâs clinical practice. Blood besides blood products offers exceptional and lifeâsaving curative advantages to patients. Nevertheless, because of resource limitations, it is always impossible for the product of blood to get to the patient promptly. The primary concern from the viewpoint of both recipient and clinician remains for secure, efficient as well as quality blood to be accessible when needed (Bowden & Greenberg, 2012).
I chose this incident because of a number of reasons. Importantly, ignorance among healthcare providers is always an everydayâs issue as seen in the case study. This routine always leads to inferior patient care or even massive mortality rate in the hospital. With regards to blood transfusion, human error remains the most probable reason for blood incompatibility reaction. The wrong transfusion in the hospital is the result of incorrectly completed forms, mislabeled blood, or a failure of checking donated blood prior to the transfusion. Ideally, this is incidence that can be prevented by healthcare providers. The incident is relevant to my professional practice on the grounds that patient identification mistakes in blood sampling during pre-transfusion remains a regular risk spot. These errors can lead to serious complications. However, the existing measures to deal with the basis of this incidents as well as near misses have not determined this crisis and there is a call for fresh scrutiny at this issue (Bowden & Greenberg, 2012).
The relevant factors in the clinical context that potentially contributed to the incorrect administration of a blood product are (1) failure of the Medical Officer to ensure that the blood products was clearly indicated. (2) Failure of confirming the patientâs identity at pre-transfusion sample collection as well as prior to the administration of the blood product. (3) IncorrectÂ labeling of the blood product with the patientâs at the patientâs side: surname, given name, date of birth, and UR number. This information was not confirmed and despite the fact that it failed to match the naming band as well as the cross-match request slip or request form, the nurses went on to administer the blood product.
If I was involved in a similar clinical situation in the future, the alternative actions that I would take prior to the blood product collection of for transfusion are that I will implement a number of aspects. Make sure that there is a legitimate prescription as well as obtained informed consent. (2) To ensure that the transfusion only starts at the time there are sufficient numbers of qualified personnel available to scrutinize and check the patient. However, this should comprise of two personnel to do the patient identity and blood product checks at the bedside. Also, there should be admission to emergency therapeutic support. (3) I will make sure that there is the last bedside check so as to prevent transfusion errors. I will ensure that it takes place before starting the transfusion process. Also, other staff and I will have to remain vigilant to make sure that the correct blood or blood product is given to the correct patient. (4) I will ensure that the patientâs identity is established by asking him or her to state name, date of birth, and make sure these precisely match the patient identification band and the blood product ABO slip right away before the blood goods and blood administration (Bowden & Greenberg, 2012).
Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
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