Looking back at our first day, I’m again overwhelmed with emotion thinking about the Lewis Blackman story. In the video we are able to see each and every breakdown in the system that eventually led to this tragedy. My heart breaks for the family. My heart breaks for the nurses and the doctors and all the members of the healthcare team, who I am sure felt ultimately responsible. Yet it is the system that is at fault, not any single action or single person. A system that should be there to serve and protect the most vulnerable, our sick patients, has actually been the what has fostered one of the biggest obstacles to providing safe, quality care: a lack of communication.
As a nurse, I can imagine how that night shift nurse felt when she was concerned about Lewis and attempted to call for help.… Continue reading