missing the big picture: the lewis blackman story

Missing the Big Picture: The Lewis Blackman Story

Helen HaskellMothers Against Medical Errorwww.advocatedirectory.orgHaskell.helen@gmail.com

Lewis Blackman

1985-2000

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

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

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.

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

-Peter Pronovost

Hierarchy

RespectDisrespect 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

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 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

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

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Helen HaskellMothers Against Medical Error

Haskell.helen@gmail.com(803) 312-4390