Part One The Lewis Blackman Story

Part One: The Lewis Blackman Story 1. 2. 3. 4. 5. Why does Helen Haskell start her story by talking about Lewis? a) She is talking about him because she wants people to understand and learn from the story of her son having elective surgery to correct pectus excavatum, but he died as a result of a medical error when he was in the hospital. What is Ketorolac (indications, side effects, normal dosages for 15 year old, risks and benefits)? a) Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that is indicated for short-term management of moderately severe pain, and should not be used for more than 5 days. Side effects include dizziness, headache, stroke, dyspnea, diarrhea, GI pain, GI ulcers, oliguria, renal toxicity. Normal dosage for IV ketorolac for a 15 year old is 0.4-1 mg/kg, maximum 15 mg/dose. Ketorolac is more effective than other NSAIDs in reducing pain, but there is an increased risk for cardiovascular thrombotic events, myocardial infarction, stomach bleeding, mild to moderate renal impairment, as well as hepatic impairment (Vallerand & Sanoski, p.730-732, 2017). What was the significance of lack of urine output (to underlying problem, amount of Ketorolac, and need for fluids)? a) Lack of urine output signifies that not there was not enough fluids going into Lewis’s body. Ketorolac is associated with renal toxicity, and Lewis was receiving a full adult dose of IV Ketorolac and he was not prescribed enough fluids resulting in his kidneys not being able to properly function. If he was given enough fluids that would have increased his urine output reducing the possibility of renal toxicity. Nurses must be alert for altered fluid required requirements in various conditions, like after surgery (Hockenberry, Wilson, Rodgers, p. 736, 2019). The nurses knew Lewis came from surgery, so assessing urine output should have been a high priority on their list. What are possible reasons why health care providers dismissed implications of undetectable blood pressure? Why would they think it was equipment failure? a) Reasons why health care providers dismissed implications of undetectable blood pressure is because they probably didn’t think it was likely that a healthy 15 year old boy was going to develop complications from having an elective surgery. They didn’t notice any signs of Lewis’s deterioration and just assumed that his undetectable blood pressure was due to equipment failure. Do you agree that it was significant that Lewis’s crisis developed on the weekend? Explain why or why not. a) I agree that is was significant that Lewis’s crisis developed over the weekend because during this time there is less staff that is working as opposed to during the week when they do have more staff available. If there were more staff available, then someone may have caught the signs early and intervened appropriately. 6. Lewis died from septic shock. Describe the incidence, signs/symptoms, and appropriate interventions for this problem. a) Septic shock is caused by an infectious organism resulting in an infection that triggers the inflammatory response in a local area which results in vasodilation, increased capillary permeability, and maldistribution of blood flow. Signs and symptoms include subtle alterations in tissue perfusion and unexplained tachypnea and tachycardia. Management of septic shock involves measures to provide hemodynamic stability and adequate oxygenation to the tissues and the use of antimicrobials (broad-spectrum antibiotics) to treat the infectious organism ((Hockenberry, Wilson, Rodgers, p. 752, 2019). Part Two: A Mother’s View of ‘Lessons Learned’ 1. Create a list of the characteristics Helen Haskell ascribes to a “good” or professional nurse/physician. a) Has sufficient education and training b) Able to recognize and respond to patients in an emergency situation c) Educated on side effects of medications d) Able to complete tasks while recognizing any deviations from normal, and taking the appropriate action e) Being able to use critical thinking and look at patient as a whole f) Listens to the patient and is as an advocate for them g) Able to have good communication skills as well as show empathy h) Has the knowledge and courage to advocate for patients 2. When Helen Haskell says “patients need to be empowered and nurses need to embrace it”, how do you react to her suggestion? a) Patients need to question the care that is being given to them and they should be able to get answers that are understandable and accurate. Nurses must listen to what the patient and family has to say and include them in the plan and take their concerns into consideration. 3. What does Helen Haskell mean by “misplaced professionalism”? a) “Misplaced professionalism” is dismissing patients’ concerns and not really listening to what they have to say. It includes thinking you know more about the patient than the patient himself or his family. It also includes not having the knowledge on what to do in certain situations. 4. In her story, did you think of other examples of “misplaced professionalism”? a) Other examples of “misplaced professionalism” I can think of are the nurse ignoring what the patient has to say because the nurse may not think anything is wrong on the outside, even though there might be signs of something going wrong internally. 5. What is professionalism in your view? a) Professionalism in my view is means treating patients with compassion, respect, and dignity to name a few. It means to be up to date with current practices and building knowledge, as well as holding one’s self accountable for their actions. 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? a) The development of policies can help empower nurses because it will help them speak up and communicate. There are some nurses who are hesitant to communicate with the physician, but having policies in place will aid in better communication and improve patient care. Part Three: Patient-centered Care and Teamwork / Collaboration 1. What factors in this hospital’s “teamwork” culture might have contributed to the lack of response to Lewis’s parents’ concerns? a) Communication is what lacked between Lewis’s health care team. The staff that was there did very little communication between none another and his parents’ concerns were ignored repeatedly, and no one stepped in to address these concerns. 2. How might this story have changed if patients and families were considered part of the health care team? a) If patients and families were considered part of the health care team Lewis would still likely be alive today. The nurse could have communicated with the parents and relay their concerns with the physician. 3. When Helen Haskell says she saw almost no evidence of teamwork, would you agree or not, and why? a) I would agree with Mrs. Haskell because communication is a part of teamwork but there was so sign of that during Lewis’s hospital stay. The nurse should have taken the time to listen to the needs and concerns of the family. Effective communication would have increased trust between the patient/family and health care team as well as help prevent complications and death. 4. How does the culture in hospitals in which you have worked compare to the culture described in Helen Haskell’s story? a) I don’t work in the hospital, so I don’t know firsthand the culture in the hospital. But I know in many hospitals they are short-staffed on the weekends, just like how it was described by Mrs. Haskell. 5. What can health care professionals do to create a hospital culture that supports effective teamwork and patient-centered care? a) I believe communication is the key to support effective teamwork and patientcentered care. The health care team members need to communicate the plan of care with each other as well as what to do to prevent complications before they turn fatal. If this was done, then the quality of care would improve, and the patient would have likely not lost their life. Part Four: Disclosing Error and Accountability 1. What does professional accountability mean to you? a) Professional accountability means being aware of one’s actions and taking responsibility for those actions, as well as taking the right steps to fix those actions when a problem arises. 2. How do health professionals demonstrate: a) A feeling of accountability for the reliability of the system in which they work i. Holding one’s self accountable is a widespread problem, and knowing that may give health care workers the drive to hold their self accountable and correct any errors to improve patient outcomes. b) Lack of accountability for the reliability of the system in which they work i. Some health care workers may demonstrate lack of accountability by not owning up to their actions, they may try to push aside any errors they made in order to not get in trouble. 3. 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? a) Nurses should never fall into the habit of just completing tasks to get them done. Mrs. Haskell’s description of nursing care in regard to nurses just completing tasks is something that I have not observed firsthand, but the nursing care I have observed included doing an accurate assessment, monitoring and listening the patient, and using knowledge and nursing judgement to improve patient outcome. The number of patients, fatigue/burnout of nurse, and an understaffed unit can contribute to “misplaced” work focus. 4. Describe what happens in your current health care setting if someone is involved in an error? a) I do not currently work in a health care setting, but I have prior knowledge that an incident report would be filled out and the error is talked about in regard to figuring out how it happened and what can be done to prevent it so it doesn’t happen again. 5. What errors happened in Lewis’s story? a) Lewis was given an adult dose of Ketorolac and was not given enough fluids. His lack of urine output was not recognized and addressed. The staff did not use their clinical judgment and assumed it was equipment error when he had an undetectable blood pressure. Nobody intervened when his vitals were outside normal parameters. Concerns brought up by the patient/family were ignored and the request to call the physician was ignored as well. There wasn’t a timely response to start resuscitation. Overall, there was a lack of communication. 6. Which of the errors you described were “system” errors? Which were errors that individuals committed? What distinguishes these categories in your view? a) Individual errors include not recognizing lack of urine output, assuming equipment error, not intervening when patient has abnormal vitals, ignoring patient/family concerns, not notifying physician, lack of response time to resuscitate, and not giving the correct dose of Ketorolac and IV fluids. A System error can include insufficient staffing. The weekend shift at the hospital has less staff which contributed to lack of communication and the heal care team not being on the same page. An individual error can occur because the nurse was careless or didn’t have the knowledge. A system error can occur even if policies are set in place. 7. 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? a) I would have wanted them to take responsibility for their actions and to apologize and show genuine remorse for their actions. I would tell them that they need to put in place a plan that prevent this mistake from ever happening again. Part Five: Transparency and Courage 1. What is it about being a learner that can help prevent errors and adverse events? a) When you are a learner you want to learn and do things the correct way so you will be attentive to detail and ask questions when they need clarification or are unsure about what to do. 2. What is it about being a learner that can increase the risk of errors/adverse events for patients? a) Some learners might have the notion that they know exactly what they’re doing and may do things thinking it’s the correct way, when in reality it’s wrong. 3. What policies or safeguards could help protect patients and families from a health care team’s inability to recognize a developing problem? a) Patients can be given the contact number of the provider in case they want to contact him/her, as mentioned by Mrs. Haskell. The patient/family and health care team could communicate before, during, and after the shift to discuss the plan of care, and what to do before/if a complication develops. 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? a) Even though it may seem good to think positive and hope everything’s going to be okay when caring for the patient, we also need to have the mindset that something could go wrong at any time and it’s important to plan for those complications in advance. 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? a) I honestly don’t think health care professional can justify this reality. If the patient wants to contact the physician, their contact information should automatically be given to the patient. If a patient has a concern, the nurse should give his/her undivided attention, and help in any way they can to address those concerns. 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? a) If the patient has any concerns or feels as though there may be a safety issue, they should communicate with the nurse, and the nurse must thoroughly listen to what they have to say and respond and take action in the appropriate manner. Nurses must do everything in their power to advocate for their patients. They might not be in alignment when the nurse is buried in trying to complete her tasks and documentation. 7. What kind of courage do you think Helen Haskell believes we need to prevent Lewis’s story from happening again? a) Nurses need to have the courage to speak up and intervene when they think something is wrong. They should have the courage to truly listen and take action as necessary.