Medical Error: The Case of Lewis Blackman

Overview of the Lewis Blackman's Case

The story takes place with Helen Haskell speaking on her son Lewis Blackmon and how negligence took away his life. She describes her son as an intelligent, innocent and simply all-around American child. She wants everyone to know that her child mattered deeply to her and that he was not just another medical case that can be sweep under the rug. She wants everyone to know that Lewis was an exceptional child with a bright future ahead of him and all that was taken away due to a deadly medical error. Mrs. Haskell is telling her and her son’s story as a cautionary tale in hopes that a tragedy like this can be avoided in the future. Lewis Blackmon was admitted to the Medical University of South Carolina’s Children Hospital for elective surgery due to history of pectus excavatum. Lewis was started on Ketorolac by a young senior resident after his surgery for pain. Ketorolac, also known as Toradol is classified as an anti-inflammatory and is used to treat moderate to severe pain. The side effects of this medication consist of nausea, diarrhea, dizziness, itching, indigestion, heartburn, abdominal pain, drowsiness, rash, rectal bleeding, urinary frequency, urinary retention and anaphylaxis. According to Cooper, McNicol and Rowe (2018), “0.5mg/kg as a single or multiple dose regimen or 1mg/kg single dose with 0.5mg/kg for any subsequent doses is deemed safe”. Mrs. Haskell states that her son Lewis was given an adult dose of this medication and reports that he did not receive the proper assessment after the medication was given. An adult does of Ketorolac can consist of up to 15mg/mL, 30mg/mL or 60mg/2mL. According to Burchum and Rosenthal (2019), “Ketorolac can cause adverse effects such as peptic ulcers, GI bleeding, prolonged bleeding, renal impairment, hypersensitivity reactions, suppression of uterine contracts and premature closure of the ductus arteriosus” (pg. 860).

Lewis experienced major adverse effects occurred while Lewis was on this pain medication. He went into kidney failure and also developed a duodenal ulcer. Helen Haskell stated that Lewis was receiving pediatric IV fluids with no urine output. Urinary retention was a side effect listed for the medication and no one decided to take that seriously. The fact that Lewis was given an adult dose of Ketorolac and received pediatric IV fluids with no urine output created major complications. He did not receive the accurate amount of fluids needed to reduce the possible side effects from the ketorolac given. Due to Lewis’s age, profile and healthy health status the nurses and healthcare providers did not factor in the potential for him to experience side effects and adverse reactions to the drug. They dismissed crucial medical complications and were unable to handle the patient once he started to deteriorate.

Lewis’s condition worsening over the weekend could have been due to understaffing or difficulty with reaching the primary physician over the case. Those factors do hold significance, but it does not excuse the actions of the healthcare team. If the nurse was more vigilant with the patient’s care, she would have noticed that his condition started to take a turn for the worse. The patient went 24 hours without urine output and then 4 hours without detectable blood pressure. The nurses and techs in the unit spent 2 hours rotating out blood pressure cuffs to different sites instead of getting in contact with the veteran physician. Lewis eventually went into septic shock due to a large amount of blood loss in his abdomen and developing an infection. According to Capriotti and Frizzell (2016), “Septic shock is defined as a state of severe sepsis with persistent life-threatening hypotension that is refractory to fluid replacement and vasopressors.” (pg. 1108). Lewis showed signs of pallor, severely worsening abdomen pain, weakness, abdominal distention, cold sweats and hypothermia. Lewis was showing all of the deadly signs and symptoms of acute abdomen. Acute abdomen is a life-threating medical condition that must be treated quickly. According to Capriotti and Frizzell (2016), “Septic shock is a medical emergency and has a high death rate-up to 60% mortality” (pg. 1108). If the condition was caught in a timely manner, it could have been treated with interventions such as surgery, antibiotics and fluid resuscitation.

Helen Haskell talks about how her child suffering at the hands of poor medical care and states that there should be provisions and mandated requirements to prevent these situations from happening. Nurses and physicians need proper training for emergency situations, professionalism, critical thinking skills, proper education on the medications and being able to listen to medical concerns from the family. Patients and families need to know that they are involved in the plan of care to provide the best possible outcome. Questions need to be asked and those questions need to be answered so a better relationship can be developed. Keeping both the family and patient informed with proper communication could have prevented a snowball effect which lead to Lewis’s death. Mrs. Haskell states multiple times that the nurses were unprofessional. This was evidenced when Mrs. Haskell reported that a young nurse was chatting outside of her son’s room and laughing when she could have been providing lifesaving care. By not acting on the information provided to her by the Mrs. Haskell, she failed in her medical responsibility. Complaints expressed by the patient and family should always be taken seriously and the nurse should never think that she knows her patient better then the patient or the patient’s family. By the nurse dismissing Mrs. Haskell’s concerns, she failed to properly care for her patient. Even if the nurse did not agree with Mrs. Haskell’s concerns, she could have still reassessed the patient and done a more thorough assessment.

Critical Analysis of the case

Professionalism in the medical setting is about honoring, respecting and advocating for the patient. It is the responsibility of the healthcare team to provide quality care to each and every patient. Professionalism means being on top of your game, possessing critical thinking skills, having compassion and being willing to listen to other. Working in the medical field requires human decency and communication as well as other qualities to maintain a standard of quality care. Every patient is important, and every family is important. By developing policies that are more empowering for the families and nurses, institutions can increase the ability to collaborate and communicate any changes in a patient’s conditions. With better communication and collaboration, the outcome would be optimal patient care.

Patient-centered Care and Teamwork / Collaboration

The medical field is constantly looking for methods to improve teamwork and efficient communication between the patients, nurses and physicians. When it came to care for Lewis, the lack of communication was noticeable. Lewis and his mother informed the nurse of his symptoms and worsening pain but their concerns we’re not verbalized to the veteran physician over Lewis’s case. The nurse is the center of communication between the physician and the patient and instead of the nurse informing the veteran physician of the families concerns, she ignored them. Lewis could have lived to see another day if the case was handled with more seriousness and urgency. If the family was able to be more involved in the care of the patient, it would have aided in how the nurse and physician took care of Lewis that day. As the mother, she did everything within her power to get the standard of care needed for her son. Due to her concerns not being addressed in the plan of care, the family will always feel that health care system killed Lewis with their negligence.

Helen Haskell states that while the nurse and resident was caring for her child, she noticed no evidence of teamwork. The lack of communication and execution between the health care team caused the death of Lewis. Not establishing rapport with the patient and the family was another error because she was unable to recognize what was occurring with her patient. If the nurse would have assessed her patient properly, she woke have gather all the necessary information needed to bring this issue to the patient’s physician. Helen states that the hospital was very quiet that night and reports that the supervisors and physician were nowhere to be found. When it come to the operation of a hospital numerous factors have to be taken into account. There has been a shortage of nurses for years and majority of the new nurses are placed on night shift to help build up their skills. Doctors are also more difficulty to reached over the weekend and some even tell the nurses to not contact them. If the healthcare team could take the time to properly educate, evaluate and explain certain information to the patient, life threatening situations can be prevented. Taking the time to get to know their patients and examining the medical records would also help to improve the hospital setting. Also making sure that newer nurses are properly trained and supervised is another factor that could help to improve patient-centered care.

Disclosing Error and Accountability

Nurses have to possess many different skills to efficient care for their patient and another important quality that is needed is professional accountability. Professional accountability is the ability of an individual to take responsibility for their actions. By doing this, it allows you to learn from your mistakes and improve yourself for future situations. The ability for a healthcare worker to own up to their mistakes is essential in the medical field. Being able to identify problems and failures in the health care system is the most efficient way to assure improvement. Lack of accountability and ownership of one’s actions is the most dangerous aspect that could occur while caring for a patient. Taking care of someone’s loved one is not a small matter. Healthcare workers who tend to turn a blind eye to errors and not own up to their mistakes because they are afraid of punishment.

From what I observed, Helen Haskell was right about the nurse not conducting a proper assessment and using attentive listening. If the nurse would have kept track of Lewis’s urinary output, blood pressure, pain level and listened to the complaints of the family about his presentation, she would have noticed that the patient was experiencing adverse reactions to the Ketorolac. On the other hand, Mrs. Haskell needs to take into account that nurses do multiple things throughout a shift. This does not excuse the negligence, but it helps understand both sides of the story. Nurses are giving several different medications a day, juggle multiple patients, charting and caring for high acuity patients. The likelihood of a nurse missing something or making a mistake is possible, but this medical tragedy that occurred with Lewis does not completely on the nurse’s shoulders. If a healthcare worker makes a mistake, it is required that they monitor the patient closely to make sure there is no adverse reactions occur before reporting the error to their supervisor. The nurse must then fill out an error form and report the factual set of conditions that led up to the event. After the form is reviewed, education is given, and the necessary steps are taken for medical improvement. Numerous system errors were made while taking care of Lewis. He was given an adult dose of Ketorolac with inaccurate amount of fluids, family concerns were ignored, adverse effects went unnoticed, vital signs were not taken and the veteran physician was never notified.

Summary and Reflection

A system error is the failure to follow protocol and regulations that are put in place by the healthcare system. An individual error is when there is a lack of skill or knowledge by an individual for a certain task. The nurse made an individualized error when she was not situationally aware, lacked knowledge about Ketorolac, failed to listen to the concerns of the patient’s family, failed to conduct a physical assessment of the patient, failed to evaluate the patient’s vital signs and failed to notice renal impairment. System and individual errors were both made while caring for Lewis and this was due to the most critical error of them all, lack of communication. If you were a person who found yourself in this situation, you may desire for the head nurse and the resident to take full accountability for the mistakes that were made. You would want them to acknowledge the fact that they made a mistake. They would have to look you in the face and confess to the fact that they did not listen to the concerns that were expressed, which ultimately compromised a love one’s care. It would help to bring closure to the situation by them stating “I am sorry”.

When you are a learner, it is best to ask for help when you feel like you are in over your head. It is best to start by eliminate all of the worse scenarios that could happen instead of dismissing medical signs and symptoms. An ego can be dangerous as a learner and it is best to find a more experienced healthcare worker for advice when you don’t know what you are doing. Communication is always an efficient way to prevent any problems from developing. Keeping your patients in the loop is actually beneficial to the healthcare team as well as the patient. Monitoring the patient’s temperature, blood pressure, oxygen saturation, heart rate, intake and output and medications are all safeguards to prevent medical errors. Making sure you check on your patients every hour is also another way to put a stop to any medical problems.

Instead of patient always believing that healthcare workers are watching for complications to rescue them from, they should be well informed that healthcare workers are doing everything they can to prevent any complications from happening. This message should ring loud and true by the care being provided to the patient. There should not be a power struggle between the patient and receiving quality care. When concerns are expressed, they should be taken seriously and not pushed to the side. Those concerns should be addressed and if the nurse is not equipped to handle those concern, she should report those concerns through the chain of command. Patient empowerment is an important part of patient-centered care. One of the roles of a nurse is to be an advocate for her patient by giving them the necessary information needed to meet their healthcare needs. Nurses and patients should have the best relationship out of the entire health care team and that relationship should be built on respect, trust and communication.

Communication is the key to preventing another patient from going through what happened to Lewis. Nurses and patients need to find the power within themselves to speak up and advocate. A nurse’s ability to communicate and advocate can affect the outcome of a patients care tremendously. All medical professionals involved in a patient’s care should exercise a collaborative team approach in order to facilitate an optimal outcome for the patient. Effective communication is pertinent in any chain of command.

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