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Case 1: "It is Hard to Kill a Healthy 15 Year Old" (The Story of Lewis Blackman)

This was a very tough read; extremely tough. There were several things that occurred that were "wrong" in my eyes.  My opinion on the first mistake was the procedure itself; the surgeon should/could have briefed the family on why the operation took longer than the anticipated 45 minutes; and also could have informed the staff in the recovery ward (assuming they weren't notified). I believe with that privileged information that maybe, just maybe they would have been a bit more compassionate for the patient and his family. The second avoidable mistake is the ward's lack of concern for Lewis's lack of bodily fluid. For over 4 days, the staff chalked up the unfortunate displayed symptoms of the medication Lewis was prescribed, which the latter physician wondered about the reason for not changing the medication if the symptoms were intolerable. As for the Lewis Blackman Patient Safety Act, I do believe it was a sufficient response to the tragedy that happened. I would also like to believe that the Family of Lewis Blackman had some oversight as to what they felt would have been proper care for their loved one, or what could have prevented such an untimely loss.

References.

Johnson J, Haskell H & Barach P: Case Studies in Patient Safety foundations for core competencies