Case Study. Incorrect administration of a blood product 
This incident draws attention to checking procedure roles and responsibilities for blood products. 
An 86 year old man was admitted with a fractured neck of femur, scheduled for surgery that afternoon. The patient’s international normalised ratio (INR) was elevated at 1.6, and the decision was made to treat this elevated level with a unit of fresh frozen plasma (FFP) prior to surgery. The medical officer (MO) went to the laboratory to collect the unit of FFP. On arrival the scientist pointed to where the FFP was located and requested the MO to sign the unit out of the laboratory in the blood register. The unit collected by the MO was allocated for another patient and labelling not yet completed. The MO signed the unit out against his patient details in the blood register without checking the product details matched. He then took the unit to the ward. 
On return to the ward the MO handed the FFP to the nurse caring for the patient, who was unaware of the request for transfusion. The nurse noted the lack of paperwork accompanying the FFP and sent the patient services attendant (PSA), with the unit, back to the laboratory to collect the appropriate paperwork. The PSA returned and stated that there was no paperwork for this FFP unit and that it did not need to be checked, although the laboratory staff stated they did not speak to the PSA regarding the FFP. 
The nurses on the ward took the word of the PSA that they did not need the paper work, and checked the FFP to the patient. The unit was group O, the patient’s blood group was group A, therefore making this an incompatible transfusion. The staff were unaware of this at the time as both medical and nursing staff were under the impression that O was the universal group for FFP as well as red cells. Later the laboratory staff noted the FFP for the patient was still in the fridge and when they checked the register realised the error. They immediately rang the ward; however the product had already been administered. As a result the patient had a mild rise in bilirubin, and his procedure was delayed as a precaution to monitor the patient for further consequences of the transfusion therapy. 
Assessment: Individual Critical Reflection paper 
Weighting: 35% 
Word Count: 1000 words 
Aim of assessment: 
The assessment develops individual skills for critical reflection and the application of clinical reasoning in practical situations. Students analyzed a professional practice issue in relation to the context of nursing that was discussed during group activities in the four workshop. 
Details 
Students draw on the National Safety and Quality health Service Standards and the NMBA professional competencies and standards to develop a critical response to a clinical incidents. Students self – select a clinical incident discussed in the workshops, and write an individual critical reflection paper. The incidents is: 
A. Incorrect administration of a blood transfusion. 
Students analyse the clinical incident from the perspective of a new graduate registered nurse in the first twelve months of practice. Use the following points to guide your answer 
1. Provide concise description of the incident (i.e. what happened?) 
2. Outline why you choose this incident and how it is relevant to your professional practice 
3. Identify the relevant factors in the clinical context that potentially contributed to the incident (i.e. why did it happen… so what?) 
4. If you were involved in a similar clinical situation in the future, what alternative actions would you take? 9i.e. what would you do differently… now what?) 
Support your answer with reference to the relevant clinical and professional standards that apply. 
Students directions 
The marking criteria and standards have been developed to guide you through the group assessment process. Please read the criteria and standards carefully. 
The paper must include in-text citation and a reference list at the end of the paper in the APA style 6th edition. (a minimum of five reference is expected).

Nursing Informatics

Review the information in Figure 6–2 in Nursing Informatics and the Foundation of Knowledge.
Chapter 6, “Overview of Nursing Informati’s”

Develop a clinical question related to your area of practice that you would like to explore.

Consider what you currently know about this topic. What additional information would you need to answer the question?

Using the continuum of data, information, knowledge, and wisdom, determine how you would go about researching your question.

Once you have identified useful databases, how would you go about finding the most relevant articles and information?

Consider how you would extract the relevant information from the articles.

How would you take the information and organize it in a way that was useful? How could you take the step from simply having useful knowledge to gaining wisdom?

Summarize the question you developed, and then relate how you would work through the four steps of the data, information, knowledge, wisdom continuum. Be specific.

Identify the databases and search words you would use.

Relate how you would take the information gleaned and turn it into useable knowledge.

Can informatics be used to gain wisdom? Describe how you would progress from simply having useful knowledge to the wisdom to make decisions about the information you have found during your database search.

Your paper must also include a title page, an introduction, a summary, and a reference page.

FYI: the writer can create any question and create a title, the paper is on Nursing Informatics. This book need to be use as part of the reference: McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning. Chapter 6, “Overview of Nursing Informatics”