They Should Have — Reflections From Day 1 at #TPSER8

Watching today’s video about Lewis Blackman’s story elicited emotional reactions from just about everyone in the room.  Personally, I felt a combination of frustration, dread and sadness throughout the film. It was clear to everyone that faulty assumptions, lack of communication, and a refusal to look at the situation objectively lead to Lewis’s unnecessary and very tragic death.

Because many of the problems were so glaring, my initial reaction was simply to say, ”well, the nurses simply should have called the doctor,” or ,”the resident should have listened to the mother.”  In the aftermath of such inadequate medical care, the problems look so simple, and saying “they should have” sounds like it makes sense.   And while it’s true that a more attentive resident or a bolder nurse could have saved Lewis’s life, I don’t think that’s the real issue.  Rather, what stuck with me all… Continue reading →