Lewis Blackman

Day 1: Lewis, Domino, and Sponge

Recap of what I applied to my learning and follow-up questions:

Intro:

  • “Educate the young, regulate the old”
    • Witty and sensible to an extent, but does it work when the young have to work under the shadow of the old? Medicine is a top-down hierarchy, and bottom-up change is not only insurmountable but also often not sustainable.
    • At the same time, becoming a positive deviant has its own value that cannot be diminished. I just wonder whether there is concurrent top-down efforts.
  • What can I do with Institute for Healthcare Improvement (IHI)? I would like to learn more.

Movie: Lewis Blackman (patient) and Helen Haskell (mother)

  • The patients and families need to know that night times and weekends the level of care is not the same. It is recommended to have a caretaker at bedside, and why not admit the systemic weakness and invite them… Continue reading

Going the distance….

At the close of our first day in Telluride, I find myself hopeful.  Today we were presented with the story of Lewis Blackman.  The tragedy of medical errors involving his case were not in vain. I believe we have become a culture that would protect Lewis Blackman if he were in our hospital today.   I found myself surprised by how far we have come in patient safety in the last decade.  And I feel confident many of the failures of his case would not occur today.  Am I foolish to be this hopeful?  I believe we as a medical community have learned from our past and strive to not repeat it.  Safety mechanisms are now in place that would have prevented Lewis Blackman’s tragic end.  At Medstar GUH, we have a list of mandatory events that demand contact with the on call… Continue reading

Reflections on Lewis Blackman

Unfortunately, there were countless errors from before the start of Lewis’ surgery all the way through the handling of his death. The one systematic error I will comment on is physician-patient communication.  Every patient undergoing a procedure needs to sign an INFORMED consent, which includes understanding the risks, benefits and alternatives to the treatment being offered. The situation continued to tailspin into a downward spiral as family was unaware of the expectations post op.  There were multiple efforts made by the patient’s mother and nursing staff to notify the physicians that something was wrong.  The physicians ignored the most valuable resource available to them, Lewis’ mother, who knows him better than anybody else.  Her concerns were repeatedly disregarded or ignored because the doctor did not want to believe something was wrong.

Dr Levy eloquently stated, ” if you can’t see your mother/sister/daughter/son in your patient,… Continue reading

Slowing down to Speed Up

Day one reflection–Telluride East

by Scott Emory Moore

“We don’t run in the ER.”  

Early in my career as a new graduate nurse in a Level 1 Trauma Center, I remember hearing these words.  I do not remember why the nurse said this to me at the time, may not quite be the same reason as it comes to mind now, but it is a valuable lesson none-the-less.  In reflecting on my first day at Telluride East, it is evident to me that one person’s hasty actions can have tremendous impacts on outcomes and patient experiences.

Often in the healthcare industry we are quick to focus on speed and time rather than diligent and deliberate precision in the execution of the interventions.  Getting caught up in the fervor of the emergent situation does no good for us, rather it is when we slow down and… Continue reading

Day One: Telluride East Reflections

By Linda Hunter, RN, PhD Student

I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have… Continue reading

The best advocate

By John Joseph, MS2 Wayne State School of Medicine

We completed the first day of the Telluride Patient Safety Summer Camp and I can say already that I am so glad I took the time to make the trip out. Telluride is a beautiful place and the enthusiasm and passion of the participants and leaders has reignited my interest. The lesson that stood out the most to me today was the video put together by Drs. Mayer and McDonald on the heartbreaking case of Lewis Blackman. His mother, Helen Haskell, fought tremendously for Lewis while he was in the hospital (and she continues to fight the system that killed him to this day) after a routine surgery. She trusted her instincts that something was wrong and repeatedly pushed for more senior physicians to examine Lewis, over and over and over. I was shocked that despite her insistence, that her requests… Continue reading

Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.