Professional development and ethics 1

Indus College of Nursing and Midwifery

NU 633: Professional development and ethics

Reflective Log

Raja Fawad Manzoor

Post RN BSN Year I, Semester III

Facilitator

Muhammad Rafique Siyal

29th-January-2022

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REFLECTIVE LOG
TOPIC: BLOOD TRANSFUSION ERRORS

DESCRIPTION:

When I was assigned to my working place, I perform physical assessment during the

over. During the round, I observe that the nursing staff was talking to another staff

about the blood transfusion through vitalia software which is used for systematic

blood transfusion. The nursing staff told that he scanned the wrong MR( medical

record number) for blood transfusion. Due to this, blood has been transfused to the

wrong patient. This is a huge medical error, although the blood transfusion was

stopped as soon as it was found to be transfused to a wrong patient.

Blood transfusions are lifesaving medicines which require basic consideration to forms and points

of interest. In the event that forms are not taken after, egregious mistakes can lead to

sentinel occasions.(Elizabeth, 2021)

FEELINGS:

In this phase, I realised that how much digital literacy is important especially for the

medical and nursing staff. If staff would be aware from all the system work, he could

never have done this wrong technique. I felt guilty for the wrong blood transfusion as

the patient will be suffering from many life-threatening complications.

EVALUATION:

In this phase, I evaluate the whole scenario which I have seen. Then I realised that

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staff should have awareness session about digital literacy and especially about any

procedure in which any digital system is performed and proper documentation as an

evidence. In this way, that they use electrical techniques properly and safely.

ANALYSIS:

In this phase, I analyzed that we are unable to use digital devices, but if we take

session and experiment as demo, we can be able to understand the system that is

made for the invasive procedure. This is a better way to ensure the safety of the

patient’s health.

CONCLUSION:

In this section, we discussed about all the situation. We learned about critical

circumstances that arose from this error and also discussed about how we can keep

the patient safe from this kind of blunders.

The head nurse was informed about this event and they conduct a very special

session on this software to educate the staff.

Blood transfusion research facilities point to supply a tall quality benefit with least

hazard to patients. British rules for great hone in transfusion pharmaceutical exist,1

and most healing centers have neighborhood conventions. In case these strategies

come up short incongruent blood may be transfused, which may lead to possibly

deadly haemolytic responses. (McClelland, 1994)

ACTION PLAN:

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 The donor is asked to complete a questionnaire detailing any history of infectious
diseases and other medical issues before they are allowed to donate blood for
transfusion.
 The donor’s hemoglobin level is checked.
 Once collected, the blood is examined and screened for possible infectious agents
such as HIV and hepatitis.
 The blood from the donor is cross matched with the patient’s blood sample to check
it is compatible. Blood group is determined by the antigen profile of an individuals’
red blood cells. The most important antigens in blood typing are the ABO and Rh

 antigens. Every individual has an ABO blood type (blood group A, B, AB, or O),
which means their red blood cells may display antigen A, antigen B, both antigens,
or neither antigen. Each person is also either positive or negative for the Rh
antigen. Overall, these antigens can combine to give eight possible blood types.
 The patient is only considered for transfusion if they really stand to benefit from the
procedure. A complete blood count is performed to check levels of the various
blood components including red blood cells, white blood cells, and platelets.
Coagulation (clotting) tests are also performed.
 The blood is transfused through tubing that is connected to a needle or catheter
supplying the vein.
 The amount of blood transfused depends on the individual patient’s needs.
 During blood transfusion, vital signs such as temperature, heart rate, and blood
pressure are carefully monitored
 Some patients may get a sudden fever during or within 24 hours of the transfusion,
which may be relieved with acetaminophen or paracetamol. This fever is a common
reaction to the white blood cells present in donated blood.

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References
Elizabeth. (2021). Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses.
Patient Safety, 78-91.
McClelland. (1994). Errors in blood transfusion in Britain: survey of hospital haemotlogy departments.
BMJ, 308-352.

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