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

What went wrong:

This case displayed a cascading event of failures. It starts with limited information given by the surgeon. The limited information is not deadly wrong, but it could have been a key to keeping a healthy teen from getting a surgery they did not need. Next, the surgeon performed the operation with as described minor complications and leaves a recovering patient in the hands of another surgeon for the weekend. It is unclear if the exchange of information between the two doctors is clear and concise, but the patient is not aware of the new surgeon’s role and how to contact them.  The attending physician left the hospital without having any licensed physician available to the patient in the facility.  The communication between the nursing staff and the attending physician was non existing.  It has long been common for nurses to be afraid of disturbing the physicians they work with. This barrier of communication can be detrimental to the care of the patient.  Finally, is the employee’s ability to follow policies and procedures bring addressed.

 

Do you think the Lewis Blackman Patient Safety Act was a sufficient response?  Why or Why not?

Just like several of my peers responded, The Lewis Blackman Patient Safety Act does not help with the loss of a life. However, it does address several areas of failure within the process of communication within the hospital and with patients.  The five key things this act does are identify the staff clearly, link the patient with their attending physician, give patients multiple access points for patients to address medical concerns, give patients an initial link between them and hospital administration, and written information about the roles of all medical staff assisting in the procedure. These five steps are great if the hospital enforces them. I am a firm believer in the saying “doers do, what checkers check”.