1. The patient presented pre-surgery with deranged INR of 1.6. Fresh frozen plasma (FFP) ordered by the surgical team. Incomplete blood product checks by a medical officer (MO) and lab staff resulted in the incorrect unit of FFP being collected. The MO handed over the FFP to the ward nurse. The ward nurse noticed a lack of documentation and sent an assistant to the lab to collect said documentation. The assistant returned stating no further documentation was required. The nurse checked FFP unit against patient’s information, however, a lack of understanding of blood group compatibility by nursing and medical staff resulted in the incompatible blood being infused into the patient. Lab staff realised the patient’s correct FFP unit was still
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I chose this incident as I feel it is especially relevant to my own future practice as a new graduate nurse. An evaluation of 75 published articles from 6 nations reviewing medication errors found 75 - 85% of new nurses will commit medication errors. (Saintsing, Gibson & Pennington, 2011). Additionally, a systemic analysis spanning 28 years of medication error research found inexperience and lack of knowledge as one of the best predictors for medication errors (Keers et al, 2013). Therefore, I feel it is in the best interest of myself and any patients I will care for that I am aware and vigilant of my own innate vulnerability of being a new inexperienced nurse. Especially as it has been shown that self-awareness is an effective tool to minimise errors in the medical setting (Nendaz & Perrier, …show more content…
If I were to critically reflect on the incident using the framework laid out by Chang and Daly (2016) I would first reflect upon what I would do in order to make things better. Firstly, I would personally take responsibility for the phone call to blood labs in order to ascertain the status of the FFP unit’s documentation. I would do this because as per the NSW health policy (2012) and blood handling guidelines (2012) I am not able to administer blood products without proper documentation. Secondly, if I was unsure if my blood product was compatible with a patient’s blood group I would contact the blood labs to verify instead of relying on word of mouth of other medical and nursing staff on the ward. Thirdly, I would feel obligated to recognise when an unsafe situation is unfolding and report the risk to avoid any future near misses as per the Nursing and Midwifery standards (2016). In addressing the broader issues that would need to be consider fostering a hospital culture that encourages thorough drug checking, encourages education on proper drug protocols, and is seen to view medication errors as a failure of the hospital culture as opposed to purely the failure of the nurse. Where possible access to protocols should be readily available to ensure nurses could find and utilise information whenever they may need it. The consequences of implementing these changes will be a nursing team that is up to date and informed on the best practices, has access to the resources
I chose this incident as I feel it is especially relevant to my own future practice as a new graduate nurse. An evaluation of 75 published articles from 6 nations reviewing medication errors found 75 - 85% of new nurses will commit medication errors. (Saintsing, Gibson & Pennington, 2011). Additionally, a systemic analysis spanning 28 years of medication error research found inexperience and lack of knowledge as one of the best predictors for medication errors (Keers et al, 2013). Therefore, I feel it is in the best interest of myself and any patients I will care for that I am aware and vigilant of my own innate vulnerability of being a new inexperienced nurse. Especially as it has been shown that self-awareness is an effective tool to minimise errors in the medical setting (Nendaz & Perrier, …show more content…
If I were to critically reflect on the incident using the framework laid out by Chang and Daly (2016) I would first reflect upon what I would do in order to make things better. Firstly, I would personally take responsibility for the phone call to blood labs in order to ascertain the status of the FFP unit’s documentation. I would do this because as per the NSW health policy (2012) and blood handling guidelines (2012) I am not able to administer blood products without proper documentation. Secondly, if I was unsure if my blood product was compatible with a patient’s blood group I would contact the blood labs to verify instead of relying on word of mouth of other medical and nursing staff on the ward. Thirdly, I would feel obligated to recognise when an unsafe situation is unfolding and report the risk to avoid any future near misses as per the Nursing and Midwifery standards (2016). In addressing the broader issues that would need to be consider fostering a hospital culture that encourages thorough drug checking, encourages education on proper drug protocols, and is seen to view medication errors as a failure of the hospital culture as opposed to purely the failure of the nurse. Where possible access to protocols should be readily available to ensure nurses could find and utilise information whenever they may need it. The consequences of implementing these changes will be a nursing team that is up to date and informed on the best practices, has access to the resources