Clinical Governance for Blood and Blood Products

Hospital failures encompass all actions taken in a hospital that are carried out in an unprofessional manner, resulting in unexpected outcomes. Hospital failures might include incorrect blood transfusions, incorrect medicine prescriptions, or incorrect diagnosis. My essay will focus on a case study of a patient who was transfused with blood from the incorrect group.

A 86-year-old man was taken to the hospital and scheduled for surgery after suffering a proximal femoral fracture. The patient had an increased international normalized ratio of 1.9 and was using warfarin, an anticoagulant medication. For treatment, the patient was to be given a unit of fresh frozen plasma before the surgery that was to happen that afternoon. The medical officer went to collect the unit however he took the wrong unit that was allocated for another patient. Without cross-checking the details of the unit he took, he signed the product out against the patient’s particulars and took it to the nurse in the ward.

The nurse realized that all the paper work needed for the unit to be administered were not available and sent the patient services attendant back to the laboratory who later came back saying that because there was no information about the unit, there was no need for confirmation. The patient services attendant’s statement was not supported by the laboratory staff as they said they never spoke to anyone about the freshly frozen plasma unit.

The transfusion was conducted, but the blood was incompatible with that of the patient’s as the unit was blood group O and that of the patient was A. All the medical practitioners believed that the Blood Group O was the universal donor for both Erythrocytes and fresh frozen plasma. The mistake was realized too late when the transfusion had already and the patient had to be delayed for surgery as a precaution to monitor him . The error in the transfusion resulted in the rise in bilirubin thus the patient had to be kept under strict observation to check whether there would be any adverse effects of the transfusion on the patient.

Blood and Blood Products

Nature of treatments that involve blood and blood products can be lifesaving, but when competency is not upheld, they can also be fatal. Donor and recipient blood screening should be done at all times to ensure that the transfused blood is compatible with the receivers systems otherwise the results may be fatal, i.e. result in death (O’Rourke, 2007).

Clinical Governance for Blood and Blood Products

Health organizations have drafted systems that are aimed at ensuring that all practices related to blood and blood products are conducted safely (Jeanne, 2016). The systems in place will also aim at ensuring that blood policies and procedures are in line with the national commission on safety and quality in healthcare.

Risks associated with transfusion and use of blood and blood products are regularly assessed in order to manage and take needed action on the process. This assessment is aimed at undertaking regular comprehensive blood and blood products assessments to identify patient safety risks and then implement necessary action to reduce the identified risks (O’Rourke, 2007).

In clinics, healthcare professions should ensure that blood and blood products adversarial effects are included in the incidents management and investigation systems (O’Rourke, 2007). In doing so, reports on blood and blood products incidents are recorded to reduce the risks associated with the handling of blood and blood products. In the case study, such incident management and investigative systems may not have been incorporated to keep professionals alert of blood transfusion risks as noted in the case study. Risks such as labelling and assumptions i.e. those done by the nurse and patient services attended would have been avoided.

In a health facility, undertaking random quality improvements in blood and blood products handling. The aim of this practice should be to increase knowledge on the handling of blood components in an effective way that reduces possible risks of patient harm arising from transfusion practices to the minimum possible percentage. In such a case, it is possible that such quality improvements on blood transfusion practices were not done or rarely done hence increasing the possibility of blood transfusion mistakes. If the healthcare fraternity did this, they would have already embraced the importance of labelling and documentation in healthcare facilities.

Correct documenting of patient information is one of the key practices that should be noted with intensive care for the reason that a mix-up in patient diagnosis and prescriptions will result in more adverse and complex patient conditions as compared to their initial state (O’Rourke, 2007).

As part of patient treatment, the necessary healthcare workers should ensure that they accurately record and document patient names, patient diagnosis, patient transfusion history and any other detailed information (Hill, 2016). In the case study, it is evident that improper documentation resulted in the mess as the FFP was not labelled which later inconvenienced the patient’s treatment schedule and got him encountering other unplanned treatment actions. Proper documentation reduces the possibilities of adverse cases arising from blood transfusion fails.

Improper documentation has also been seen to cause a lot of hitches and inconveniences in the health department as the unlabelled FFP got the nurse sending the FFP back to the laboratory for clarification. If the FFP were labelled, the nurse would have worked to deliver roles effectively. A labelled FFP would have also avoided the confusion aroused between the scientist and the medical officer in handling the FFP.

Ignorance is another factor which led to the hospital mess witnessed in the case study. If the patient service attendant avoided ignorance and assumptions, the PSA would have sought clarification from the scientist from the scientist or medical attendant and the mess would have been avoided. The nurse also portrayed ignorance at work by sidelining with the ignorant PSA that clarification on the FFP administration was not necessary. Assumptions in healthcare should be totally avoided to evade catastrophes that would have otherwise been avoided like the event in the case study.

Assumptions and lack of competent knowledge also caused the mess and this is evident where the nurses and staff had the impression that blood group O was the universal group for red cells and FFP as well. The scene portrays the level of incompetence in the hospital where health workers perform their duties on assumptions in such a sensitive field. Results of assumptions in the field of healthcare are catastrophic.

What I Would Do Differently

If I were a participant in the case study, I would work diligently to ensure that such scenarios do not occur under my scope of roles. In achieving that, I will make sure that all specimens I work with are well labelled to avoid confusions that arise up from specimen mixes as evident in the case study. Labelling helps in preventing specimen confusions (Allen & Cameron, 2017).

As a healthcare professional in the hospital, I would ensure that all activities I partake are those that I fully understand and avoid working from assumptions. Assumptions in healthcare lead to possible harm to patients and could possibly result in death depending on the nature of applied assumptions.

As a medical profession in the hospital, I would follow my conscience in doing what I know is right as per the medical policies to provide quality healthcare. I would ignore any suggestions considered null and void in the medical profession. In doing so, the scenario such as the one in the case study where the patient service attendant tells the nurse that clarification was not necessary would be avoided and consequent mistakes eluded. Following my conscience is necessary for making critical decisions.

As a medical profession, I would also seek further clarification from patients on their medical backgrounds such as their past medical history and their blood groups. If such a practice were incorporated in the case study, the nurse would have somehow discovered the mix-up by realising that the blood groups and the FPP were not compatible. Client to nurse or doctor conversations boosts healthcare delivery (Silverman & Draper, 2016).

Conclusion

In conclusion, I would recommend that all the activities that have been researched and proved to be effective in enhancing healthcare delivery should be implemented and promoted on all healthcare facilities to reduce hospital fails. Hospital staff should also be taught to be competent in their activities and gather vast knowledge on whatever roles they are required to partake.

References

Allen, D. C., & Cameron, R. I. (Eds.). (2017). Histopathology specimens: clinical, pathological and laboratory aspects. Springer.

Hill, K. A. (2016). Standardized Blood Transfusion Documentation.

Linden, J. (Ed.). (2016). Blood safety and surveillance. CRC Press.

O’Rourke, M. (2007). the australian Commission on Safety and Quality in Health Care agenda for improvement and implementation. Asia Pacific Journal of Health Management, 2(2), 21.

Silverman, J., Kurtz, S., & Draper, J. (2016). Skills for communicating with patients. CRC Press.