Day 1 Reflection: Lewis Blackman and Systems Culture

Our first day at the Telluride Experience focused on the importance of widespread communication, and the fundamental role leadership and culture plays in ensuring that effective communication takes place. In the first minutes of our lecture, we watched a Youtube video titled “Leadership Lessons from a Dancing Guy” (https://www.youtube.com/watch?v=fW8amMCVAJQ). While the video first seemed trivial, key lessons from this video permeated throughout the day. This video emphasized that leadership often involves frank vulnerability and that part of leadership is nurturing followers as equals. Through the Lewis Blackman story, we learned that vulnerable leadership and the concept of “leveling the playing field” both are essential in promoting effective communication and preventing patient safety errors.

I had never seen or heard of the Lewis Blackman story before. Briefly, Lewis Blackman was a 15-year old male who presented for elective repair of pectus excavatum. Over the next five days, multiple critical clinical signs of deterioration were missed, concerns had by both Lewis’ mother and members of the staff were dismissed, and Lewis died of shock from abdominal bleeding, secondary to medication errors. Watching a video of this healthy fifteen year old boy who presented for elective surgery and died five days later from preventable causes filled me with rage. Hearing his mother’s narrative as she watched her son deteriorate, while her calls for help went unheard and seeing how her life was subsequently irrevocably changed filled me with sadness.  More information, and Lewis’ story can be found: https://www.youtube.com/watch?v=Rp3fGp2fv88

Throughout Lewis Blackman’s story, it appeared that people were aware of the fact that the fifteen year old was facing issues in his recovery. Initially, he wasn’t creating urine, his diet wasn’t progressing and he was experiencing persistent abdominal pain that was not necessarily improving. In theory these concerns were being monitored, nursing checked vitals and physicians did physical exams. However, when concerns emerged communication failed.

Because of premature closure, or the failure to recognize reasonable alternatives once an initial diagnosis is made, critical signs in Lewis’ case were ignored. Initially, the diagnosis given to his post-operative abdominal pain was “gas”. Consequently, every time the patient complained of worsening abdominal pain or clinical signs, focused on the benign nature of the gas diagnosis, individuals dismissed these claims. Furthermore, when staff actually had these concerns, systemic cultural barriers to open communication especially in the face of the strict hierarchy of the healthcare system prevented these concerns from being heard. An agency night nurse, new to the floor, became concerned about the patient’s recovery never but never expressed these thoughts throughout the nursing hierarchy or to the physician team. When residents examined the patient, critical signs were ignored due to the fact that the initial diagnosis had already been made. When the chief resident finally went to his attending to express serious concern about the patients deteriorating vital signs, the attending dismissed him. In the Lewis Blackman case, the engrained hierarchy and the lack of a level playing field prevented individuals from communicating their concerns about the patient. The healthcare team as a whole lacked the vulnerability to challenge their initial assumptions about the patient and adapt their differential diagnosis to the evolving clinical picture. Furthermore, the leader of the healthcare team, the attending surgical physician, lacked the vulnerability to listen to his training physicians and recognize that he could have been wrong. Most egregiously, while Lewis’ mother was continuously expressing concerns about her child, no one communicated her child’s status to her until after he died. As a result of this multitude of errors,  Lewis Black, a healthy fifteen-year-old boy, died.

Prior to the Telluride Experience, I often thought of systems levels issues being associated with processes, lack of resources, poor coordination or communication among other things. However, the story of Lewis Blackman emphasized that malignant culture also is a systems level issue. No one in the Lewis Blackman purposefully made decisions that resulted in patient harm. However, at a systems level, a hospital culture that lacked vulnerability and that promoted a hierarchical structure which prevented open communication resulted in irrevocable harm and the loss of a life.

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