Missing the big picture the lewis blackman story
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Missing the Big Picture: The Lewis Blackman Story. Helen Haskell Mothers Against Medical Error www.advocatedirectory.org [email protected] Lewis Blackman. 1985-2000.

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Missing the Big Picture: The Lewis Blackman Story

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Missing the big picture the lewis blackman story

Missing the Big Picture: The Lewis Blackman Story

Helen Haskell

Mothers Against Medical Error

www.advocatedirectory.org

[email protected]


Lewis blackman

Lewis Blackman

1985-2000


Lewis blackman1

  • Healthy 15-year-old develops severe upper abdominal pain while on NSAID and narcotic pain regimen following elective surgery

  • Nurses and residents fail to act upon increasing signs of instability, including 24 hours with no urine output and four hours with no BP

  • Lewis dies four days post-op. Autopsy shows a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity

Lewis Blackman


Failures in care

  • Unfamiliarity with pediatric dosing

  • Unfamiliarity with medication contraindications/side effects

  • Failure to consider the possibility of medication reaction

  • Unwillingness to challenge incorrect orders

  • Unwillingness to change the plan

  • Failure to recognize the signs of sepsis and shock

  • Prolonged inaction in the face of alarming symptoms (“clinical futile cycles”)

  • Undue deference to hierarchy

  • Unwillingness to intervene with someone else’s patient

  • Delay in calling code

Failures in Care


Underlying issues

  • Tunnel vision

  • Bluffing

  • Task-oriented behavior

  • Overwork

  • Inadequate training

  • Inadequate backup

  • Overconfidence

  • Complacency

Underlying Issues


The lewis blackman act

  • All clinical hospital workers are identified by name, department, and status.

  • Patients are provided written information about the role of trainees in the hospital.

  • If asked, hospital staff must call a patient’s attending physician or provide the physician’s phone number to the patient.

  • Hospitals provide a means through which patients can call directly for emergency medical assistance.

The Lewis Blackman Act


Hierarchy

[I]n every hospital in America, patients die because of hierarchy.

-Peter Pronovost

Hierarchy


Respect

Disrespect is the heart of the slow progress in reducing medical errors.

It is time for medical schools to teach respect and teamwork, and for leaders in medicine and the chief executives of hospitals to enforce codes of conduct to ensure that all parties treat one another with respect.

-Lucian Leape

Respect


Patient information patients need to know

  • The reasoning behind their treatments

  • What could go wrong

  • What symptoms to watch for

  • What to do in an emergency

Patient InformationPatients need to know:


Patient survey

  • 90% of reported events were in hospitals.

  • Most complications were postoperative.

  • The most common complication was infection.

  • Doctors were implicated in nearly every case; nurses in about half; other personnel much less frequently.

  • The most common problem in medical treatment was delay:

    - Delay in diagnosis or treatment

    - Failure to rescue

Patient Survey


Planetree focus groups

Top three concerns cited by patients

  • Dismissal/trivialization of the patient voice

  • Absence of caring attitudes from providers

  • Lack of continuity in care

    * “Building A Collective Vision Across the Continuum of Care,” Planetree International, Patient-Centered Care CEO Summit, October 23, 2008

Planetree Focus Groups*


Missing the big picture the lewis blackman story

LEWIS BLACKMAN


Missing the big picture the lewis blackman story

Helen Haskell

Mothers Against Medical Error

[email protected]

(803) 312-4390


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