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Reply To Luis Blackman Discussion Board
Emily
Lewis Blackman
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This week’s case was another difficult story to watch and read about. I felt a great deal of anger and frustrating learning about the events that led up to Lewis Blackman’s tragic death. Listening to Lewis’ mother recount her experiences watching her son suffer and the handling of his care by the nurses was gut wrenching. I was appalled when I heard that one of the weekend residents was offended that Lewis’ mother asked for the attending doctor to be notified. I can imagine that the patient’s family members felt powerless over the situation. Ultimately, not doctor was ever called, and the patient went two days without seeing an attending physician. Because of the assumptions made by the care team, the nurses and residents failed to act upon Lewis’ increasing signs of instability. No one seemed concerned that this might be an emergency requiring immediate action. Lewis’ mother notes in one of the videos that one of the main problems with what happened to Lewis was that people were following protocols and guidelines and not looking at the patient. She made another comment about how in her son’s post-surgery care, nothing was coordinated, and no one seemed to be in charge of care. This reminded me of last week’s case on Elaine Bromiley, where confusion and lack of direction led to a disastrous medical error. Specifically, in Lewis Blackman’s case, the underlying issues behind the error were a lack of situational awareness, communication failure, failure to escalate, and failure to rescue.
In their recommendations for organizations, using the power of transparency, Sadler & Stewart (2015) urge organizations to commit to learning from serious clinical crises. The authors suggest that organizations conduct a thorough assessment of all clinical crises to understand and learn from failings, which will help reduce risk of future events. Outside advisers are welcomed and provide their perspective to aid in the organization’s continual learning, improving and sharing of lessons learned. Sadler & Stewart (2015) also recommend that organizations actively support compassionate patient, family and employee communication. It is important that this type of policy is made known to the entire organizations and it includes appropriate apology, rapid disclosure when harm occurs, and support. Lazare (2006) notes that the patient’s family wants to know through the apology that the physician cares about the well-being of the patient. “This is communicated through the quality of the apology, special attending afforded the patient, follow-up telephone calls, and even attending the patient’s funeral” (Lazare, 2006). Because the outcome of the medical error did result in a death, there should be the maximum amount of effort, sincerity, and attention given to the Blackman family in the aftermath of this unnecessary crisis. Lazare also suggests that the family needs the opportunity to ask questions and express feelings to the physicians, who needs to listen to such feelings and concerns and respond appropriately and empathetically. I believe that Lewis’s attending physician, along with the hospital’s senior leadership should take an active role in the apology.
Some of the specific suggestions for leadership given by Sadler & Stewart (2015) that could have been used by the hospital leadership in Lewis’s case are to “act with intense urgency, own the problem and form a crisis management team.” This feeds into another recommendation, which is to design, disseminate and regularly test a crisis management plan. Sadler & Stewart (2015) mention that this must be a written plan that is regularly tested, modified and reviewed by executive leadership, clinicians and, and the board, and is inclusive of the core principles of internal and external transparency and support for second victims. It is clear that this type of plan was neither in place nor utilized by the care team in Lewis’s case. The attending clinicians should have acted with a greater sense of urgency when Lewis and his mother were raising concerns. They did not recognize or appropriately response to these concerns and no one took ownership of the crisis. The staff and hospital leadership should use this egregious error as fuel to quickly establish an effective crisis management team to prevent instances like this again.
Lewis’s attending physician was a key stakeholder in his case, and he was not notified of Lewis’s symptoms and declining condition during the hours following his surgery. All stakeholders ought to be notified of emergency situations immediately. Another leadership tactic – “lead with your genuine feelings – empathy, outrage, sadness, and disappointment” (Sadler & Stewart, 2015) – should have been used by the nurses and Lewis’s care management team during the weekend. Instead, the clinicians disregarded the patient’s strong concerns and expressions of pain. All of these examples of failures of listening led to the tragic and unnecessary crisis of Lewis Blackman's death.
References:
Lazare, A. (2006). Apology in Medical Practice: An Emerging Clinical Skill. JAMA, 296(11).
Sadler, B. L., & Stewart, K. (2015). Leading in a Crisis: The Power of Transparency. The Health Foundation.
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Response:
The tragic demise of Lewis Blackman is the most disastrous, heart-breaking, and excruciating case of medical malpractices. The death of Lewis elucidates the connotation of all the managerial implications; generally, people think that communicational efficacy and other intertwined practices are based only on theories and therefore do not have any significance in real-life. But unfortunate cases such as Lewis remind professionals regarding the utter imperativeness of pursuing the strategically devised guidelines in a rather harsh manner. Healthcare is a somber profession because it involves the notion of life and death, and even a little slipshod can take the patients to the murky abyss of mortality. Medical malpractices are severe negligence that occurs when healthcare personnel fail to proffer adequate treatment. In the wake of their heedlessness, they provide patients with substandard treatment that can have detrimental and morbid consequences. Such malpractices are unforgivable and require legal proceedings along with concrete corrective and preventive measures.
Reference:
Pandit, M., & Pandit, S. (2009). Medical negligence: Coverage of the profession, duties, ethics, case law, and enlightened defense - A legal perspective. Indian Journal Of Urology, 25(3), 372. doi: 10.4103/0970-1591.56206
Sarah
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In this case study, Lewis Blackman and his parents were simply ignored which ultimately caused his death. Lewis Blackman went into the hospital for an elective surgery. His condition was called pectus excavatum. His breast plate was malformed and which causes his lungs to inadequately grow. His parents were told its almost like getting a tooth pulled out that it would be quick and simple. He went to the Medical University of South Carolina Children's Hospital in Charleston to get this surgery. There had been reports of successful similar surgeries. This surgery would have been placing a metal bar through small incisions and propping the breast bone up. A couple days after the surgery, Lewis was injected with Toradol for pain medication. Immediately, he experienced immense pain in his stomach. The nurses kept pushing it off saying it was consitpation due to the medication. The side effects of the pain medication was stomach ulcers. No one listened to Lewis complain, they just kept saying he had to go for a walk and to walk it off.
Ultimately, if one nurse decided to actually listen to Lewis he could have been alive today. He ended up having internal bleeding from the ulcers and lost 3 liters internally. Lewis Blackman's mom wanted to know what happened but all they did was apologize. An apology is not sufficient in this case. Not saying money is everything, but they should get something for the mental restitution for the parents. Hospital leadership should effectively manage situations like these to eliminate more medical errors. If someone actually listened to Lewis and did a simple blood test he would probably be alive today. The crisis management team would have to work with a very agitated family due to the loss of their eleven year old son. Overall, this whole situation could have been simply avoided.
Response:
“If nurse decided to listen,” “if this, and if that,” this “IF” is a substantial dilemma that should not be a part of the healthcare profession. Legendary nurses such as Edith Cavell and Florence Nightingale practically demonstrated that how a nurse should be; emphatic, compassionate, and selfless. The underlying objectives of all healthcare professionals should pivot the idea of saving lives, and for that, they need to devise and follow sustaining practices. Any rules and regulations that impede the flow or appropriateness of patients’ treatment should be strictly discouraged and dejected for the well being of humanity. Doctors are there to make things better for the sufferers; they are not supposed to add insult to the injury. Moreover, the nursing staffs mandatorily comprehend the adversaries of every drug or medicine they are permeating into patients. Age and dosage and particular circumstances of the patient are inevitable to be analyzed and justified before prescribing or giving any medications. “If” only, nursing staff would have evaluated the effects of Toradol, Lewis would have escaped from a miserable end; healthcare métier should eliminate this "if" altogether.
References:
Croke, E. (2003). Nurses, Negligence, and Malpractice. AJN, American Journal Of Nursing, 103(9), 54-63. doi: 10.1097/00000446-200309000-00017
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