Missing the Big Picture: The Lewis Blackman Story

1. Missing the Big Picture: The Lewis Blackman Story Helen Haskell Mothers Against Medical Error www.advocatedirectory.org Haskell.helen@gmail.com

2. Lewis Blackman 1985-2000

3. 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

4. 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

5. Tunnel vision • Bluffing • Task-oriented behavior • Overwork • Inadequate training • Inadequate backup • Overconfidence • Complacency Underlying Issues

9. 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

10. [I]n every hospital in America, patients die because of hierarchy. -Peter Pronovost Hierarchy

11. 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

12. 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:

13. 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

15. 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*

16. LEWIS BLACKMAN

17. Helen Haskell Mothers Against Medical Error Haskell.helen@gmail.com (803) 312-4390