The Lewis Blackman Story

Overview

Helen Haskell is the mother of Lewis Blackman, a 15-year-old boy who died in a hospital following routine surgery. The videos featured below were part of a lecture and interviews with Ms. Haskell recorded at the UNC-Chapel Hill School of Nursing in summer 2009.

Videos Part 1 and 2 present Lewis’s story and a patient/family perspective of lessons learned from a tragic outcome. Videos 3-5 include selected segments of an interview with Linda Cronenwett and the dialogue between Ms. Haskell and the audience following her lecture.

1. More About Helen Haskell

Helen Haskell is president of Mothers Against Medical Error, a South Carolina-

based group dedicated to improving patient safety and providing support for patients who have experienced medical injury. For Helen, patient safety is a calling to which she was brought by the death of her fifteen-year-old son Lewis, who died in the hospital following routine surgery. Following Lewis’s death, Helen helped create a coalition of South Carolina health professionals and consumers to pass the Lewis Blackman Act, aimed at addressing the conditions that led to Lewis’s death. Helen is a World Health Organization Patient Safety Champion and has served on patient safety advisory panels for a number of national organizations. She regularly addresses national groups of health professionals on the consumer perspective in patient safety.

In 2007, the Health Sciences South Carolina consortium named the first Lewis Blackman Professor of Patient Safety and Simulation, an endowed chair funded

by the state of South Carolina. In 2008, the South Carolina Hospital Association initiated an annual Lewis Blackman Award for champions of patient safety in South Carolina.

Ms. Haskell was closely involved in the passage of the 2006 South Carolina Hospital Infection Disclosure Act. She sits on the Hospital Infection Disclosure Act advisory committee and on the South Carolina Hospital Association Quality Council. Nationally, Helen is involved in a variety of initiatives involving such issues as health education reform, rapid response teams, disclosure of medical error, and informed consent.

Helen holds a BA in Classical Studies from Duke University, an MA in Anthropology from Rice University, and an M Phil in Museum Studies from the University of South Carolina. Her earlier career as an archaeologist included research and fieldwork in the United States, Europe, the Near East, and Africa.

2. Additional Information for Faculty

3. BSN Student Responses to the Lewis Blackman Story at UNC-Chapel Hill

Videos

Each of the following videos includes a list of questions that can be used to stimulate discussion or structure a written assignment.

1. The Lewis Blackman Story

2. A Mother’s View of ‘Lessons Learned’

3. Patient-centered Care and Teamwork/ Collaboration

4. Disclosing Error and Accountability

5. Transparency and Courage

Part One: The Lewis Blackman Story

https://youtu.be/WElE_hRucpo

• Why does Helen Haskell start her story by talking about Lewis?

• What is Ketorolac (indications, side effects, normal dosages for 15 year old, risks and benefits)?

• What was the significance of lack of urine output (to underlying problem, amount of Ketorolac, and need for fluids)?

• What are possible reasons why health care providers dismissed implications of undetectable blood pressure? Why would they think it was equipment failure?

• Do you agree that it was significant that Lewis’s crises developed on the weekend? Explain why or why not.

• Lewis died from septic shock. Describe the incidence, signs/symptoms, and appropriate interventions for this problem.

Part Two: A Mother’s View of ‘Lessons Learned’

https://youtu.be/OofpjxReEgM

1. Create a list of the characteristics Helen Haskell ascribes to a “good” or professional nurse/physician.

2. When Helen Haskell says “patients need to be empowered and nurses need to embrace it”, how do you react to her suggestion?

3. What does Helen Haskell mean by “misplaced professionalism”?

4. In her story, did you think of other examples of “misplaced professionalism”?

5. What is professionalism in your view?

6. What is your reaction to Helen Haskell’s view that nurses need policy-level help to be empowered with respect to communications with physicians?

Part Three: Patient-centered Care and Teamwork / Collaboration

https://youtu.be/mQUcXvEReAk

1. What factors in this hospital’s “teamwork” culture might have contributed to the lack of response to Lewis’s parents concerns?

2. How might this story have changed if patients and families were considered part of the health care team?

3. When Helen Haskell says she saw almost no evidence of teamwork, would you agree or not, and why?

4. How does the culture in hospitals in which you’ve worked compare to the culture described in Helen Haskell’s story?

5. What can health care professionals do to create a hospital culture that supports effective teamwork and patient-centered care?

Part Four: Disclosing Error and Accountability

https://youtu.be/Gpg7FyWcXSM

1. What does professional accountability mean to you?

2. How do health professionals demonstrate:

3. A feeling of accountability for the reliability of the system in which they work

4. Lack of accountability for the reliability of the system in which they work

5. Helen Haskell describes nurses focused on task completion (including documentation of a plan of care) rather than on accurate assessment, application of knowledge, listening to patient and family, and action on the patient’s behalf. How accurate is her depiction of nursing care you have observed? In instances where you have made similar observations, what contributes to this “misplaced” work focus?

6. Describe what happens in your current health care setting if someone is involved in an error?

7. What errors happened in Lewis’s story?

8. Which of the errors you described were “system” errors? Which were errors that individuals committed? What distinguishes these categories in your view?

9. If you were a patient or family member in Helen Haskell’s situation, what would you have wanted to say to or hear from the “frontline” nurses and residents who provided Lewis’s care?

Part Five: Transparency and Courage

https://youtu.be/QKk96qoN5Qs

1. What is it about being a learner that can help prevent errors and adverse events?

2. What is it about being a learner that can increase the risk of errors/adverse events for patients?

3. What policies or safeguards could help protect patients and families from a health care team’s inability to recognize a developing problem?

4. Patients enter hospitals assuming that health professionals are watching for complications so that they can “rescue” patients. What factors detract from our effectiveness in making that true – reliably true – for every patient?

5. Helen Haskell has stated elsewhere, “We were in the only place in this country where Lewis’s father and I could not get help for our son…a hospital.” In any other location, she could have called “911”. How do health professionals justify this reality? What policies could eliminate the problem?

6. What are your ideas about patient empowerment and nurse empowerment in terms of the overall safety of our health care systems? When are the interests of patients and nurses in alignment? When are they not?

7. What kind of courage do you think Helen Haskell believes we need to prevent Lewis’s story from happening again?