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Whose Medical Error? Insights from a Patient's Perspective

This book recounts the devastating medical error that led to a young boy's death and explores the implications of full disclosure in healthcare. The narrative sheds light on the emotional needs of patients post-injury, the importance of accountability, and the root causes of medical errors. By sharing the family's experience, it advocates for transparency, compassion, and learning from mistakes to prevent similar tragedies.

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Whose Medical Error? Insights from a Patient's Perspective

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  1. WhoseMedical Error? A Patient’s Thoughts on a System’s Response Helen Haskell Mothers Against Medical Error Columbia, South Carolina

  2. Lewis Wardlaw Blackman 1985-2000

  3. Synopsis of a Medical Error • Lewis, a healthy 120-pound boy, is prescribed a five-day adult course of the NSAID ketorolac tromethamine following surgery. • Adequate fluid levels are not maintained. • Three days after surgery, Lewis begins complaining of severe, unremitting epigastric pain. • Nurses and residents fail to act upon increasing signs of instability. • Parents’ request for an attending physician is not honored. • Four days post-op, following 30 hours of deteriorating vital signs, including four hours of completely undetectable blood pressure, Lewis dies. He has not seen an attending physician for over two days. • Autopsy shows a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity.

  4. AFTER OUR CHILD DIEDWhat we expectedfrom the hospital • Alarm; • Remorse; • Compassion and support; • Urgent investigation; • Urgent change.

  5. How Does Full Disclosure Help Patients? • It relieves guilt and fear. • It restores trust. • It allows them to believe that their healthcare providers care about them. • It reassures them that they do not have to face a dark future alone.

  6. How Does Full Disclosure Help Providers? It allows them to maintain their compassion and integrity and to fulfill their mission as caregivers.

  7. What we wanted • The option to meet with those involved in our child’s death; • The chance to tell investigators what we had seen; • The chance to have input into change.

  8. Questions • Would the residents have felt less abandoned if they had the opportunity to meet with Lewis’s parents? • Did investigators’ desire to spare the residents’ feelings prevent the residents from learning from their mistakes? • What lessons did they then learn instead?

  9. Patients’ Emotional Needs after a Medical Injury • Acknowledgment of the significance of the loss; • Learning and change; • Accountability.

  10. Root Causes of Errors Production pressure Inadequate training Poor care coordination Unsupervised trainees

  11. What do patients expect? • Expertise • Vigilance • A plan • A backup plan • A system that delivers what it promises

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