Lewis Blackman Hospital Patient Safety Act
Proper diagnosis and subsequent professional and holistic nursing practice are primary requirements for excellent treatment and full recovery of a patient. In fact, a wrong diagnosis by a health professional may lead to the death of a patient. A notable case is that of the tragic death of Lewis Blackman, which was due to an error in decision-making (Acquaviva, Haskell, & Johnson, 2013). An autopsy on Lewis body identified the cause of his death as an undiagnosed perforated giant duodenal ulcer. Specifically, the ulcer was of a type associated with nonsteroidal anti-inflammatory drugs (NSAIDs) (Newton, Versland, & Sepe, 2008). In effect, Lewis developed peritonitis and lost most of his blood into his peritoneal cavity (Nussbaum, 2012).
Lewis Blackman was a young 15-year old who had a pectus defect, which was relatively mild. Nonetheless, his parents decided to take him to hospital after learning about a minimally invasive operation procedure that could correct this abnormality. Further, they were advised that the corrective procedure would become more difficult when he was older. The surgery was successful; however, problems arose in the recovery room. Firstly, Lewis nurses noticed that he was producing abnormally low amounts of urine. In spite of this, he was prescribed a 5-day adult dose of ketorolac, which is an NSAIDs painkiller. Notably, this medication was not approved for children who were younger than 16 years. Moreover, ketorolac should be used with caution in patients who have low fluid outputs. Four days after the surgery, Lewis condition worsened. He became pale and he had a constant cold sweat.
His parents’ pleas for assistance were not properly addressed. Specifically, Lewis parents blamed the poor communication channel in the hospital for the lack of proper diagnosis of their son. In particular, they were unable to differentiate between the fully trained caregivers from the trainees. Worse still, no fully trained surgeon checked on Lewis progress on the two days prior to his death. Moreover, the professionals-in-training were unable to diagnose the real problem that Lewis was facing.
Due to the unfortunate events that led to the demise of Lewis Blackman, the Mothers Against Medical Error (MAME) group together with South Carolina hospitals passed the Lewis Blackman Hospital Patient Safety Act. This law requires all hospital personnel to wear badges that indicate their employment status. Further, hospitals are required to give patients information about the role of residents and students who are attending to them. In addition, patients have the right to contact their physicians directly (Johnson, Haskell, & Barach, 2012). Moreover, the hospital’s clinical staff members or trainees must assist the patients to access the healthcare communication mechanism. On the same breath, hospitals must provide a mechanism for addressing the patient’s calls. Finally, patients and their families have the right to call for immediate help when they feel that they need urgent attendance (Lewis Blackman Patient Safety Act of 1976).
To sum up, the Lewis Blackman Hospital Patient Safety Act empowered and emboldened the rights of patients to demand immediate attendance when they feel their situation is worsening. In addition to this, it enabled them to identify the individuals who were in charge of each of their specific needs. Moreover, it created a framework that ensured that doctors have a better understanding of their patients. In effect, this law has minimized the chances of deaths due to improper communication and negligence in healthcare facilities.
Acquaviva, K., Haskell, H., & Johnson, J. (2013). Human cognition and the dynamics of failure to rescue: The Lewis Blackman case. Journal of Professional Nursing, 29(2), 95-101.
Johnson, J., Haskell, H., Barach, P., (2012). Case studies in patient safety: Foundations for core competencies. Burlington, MA: Jones & Bartlett.
Lewis Blackman Patient Safety Act of 1976, Pub. L. Section 44‐7‐3410 and Section 44‐7‐3430.
Newton, B., Versland, M., & Sepe, T. (2008). Giant duodenal ulcers. World Journal of Gastroenterology, 14(32), 4995-4999.
Nussbaum, M. (2012). Master technique in surgery: Gastric surgery. London, UK: Elsevier Medicine.