Lewis Blackman Paper Graded

The Lewis Blackman Case: Ethics, Law, and Implications for the Future Medical errors in decision making that result in harm or death are tragic and costly to the families affected. There are also negative impacts to the medical providers and the associated institutions (Wu, 2000). Patient safety is a cornerstone of higher-quality health care and nurses serve as a communication link in all settings which is critical in surveillance and coordination to reduce adverse outcomes (Mitchell, 2008). The Lewis Blackman Case 1 of 1 point accrued

On Thursday November 2, 2000, 15 year old Lewis Blackman checked into Medical University of South Carolina Children’s Hospital (MUSC) in Charleston for elective surgery on his pectus excavatum, a congenital deformity of the anterior chest (Monk, 2002). Due to issues with insurance coverage, a year had elapsed since Lewis and his parents’ last appointment with the surgeons; however, the office had not required another evaluation prior to his surgical date (Kumar, 2008). During the pre-operative intake process a nurse asked Lewis how much he weighed instead of performing an actual measurement (Kumar, 2008). After insisting on a current value Helen discovered that his weight was 120 pounds, less than he had admitted to (Kumar, 2008; Monk, 2002).

While Lewis was in surgery, his family became increasingly worried when the estimated surgical time elapsed without word (Kumar, 2008). Dr. Tagge, the lead surgeon, finally updated the family over two and a half hours later stating that Lewis did well even though he had to reposition the metal bar four times for correct placement (Kumar, 2008; Monk, 2002). Helen reported wondering if Dr. Tagge had realized how much Lewis’ chest depression had deepened since he last saw him a year ago in the office, especially considering he did not lay eyes on Lewis until he was under anesthesia the day of surgery (Kumar, 2008). In the recovery room, Lewis was conscious and alert with good vital signs, listing his pain as a three out of ten (Monk, 2002). Nurses and doctors in the recovery area charted that he had not produced any urine in his catheter despite intravenous hydration (Kumar, 2008; Monk, 2002). Epidural opioid analgesia was administered post-operatively for pain control, but was supplemented every six hours by intravenous Toradol (Ketorolac) (Kumar, 2008; Solidline Media, 2010).

Following his recovery from surgery, Lewis is was sent to the children’s oncology unit related to a shortage of available beds on the surgical floor (Monk, 2002). Saturday morning at 9:00am, a new physician, Dr. Hebra, assessed Lewis since Dr. Tagge had gone for the weekend (Monk, 2002). His charting included no evidence of infection and clear lung sounds with a recommendation to consider getting out of bed (Monk, 2002). That evening a slight fever developed and Lewis was noted to have cold feet; he was still also receiving intravenous Toradol (Monk, 2002). Sunday, the third day out of surgery, Lewis developed sudden severe abdominal pain which staff referred to as gas pains and recommended that he walk around the ward (Solidline Media, 2010). Throughout the day Lewis appeared to be getting weaker with the following symptoms: pallor, continued pain, diaphoresis, and an increasingly swollen and firm abdomen (Monk, 2002; Kumar, 2008).

Helen repeatedly asked for an attending physician to evaluate him after her initial request was answered by a new, first year resident (Solidline Media, 2010). Dr. Murray, the chief resident who arrived around 8:00pm, charted Lewis’ heart rate as normal and noteds a probable ileus; however, nursing documentation at the same time recorded a heart rate of 126 beats per minute (Monk, 2002). Subsequent heart rates at midnight and 4:00am arewere charted as 142 and 140 beats per minute respectively without documented intervention (Monk, 2002). On Monday morning Lewis noted that his pain suddenly stopped after being very constant and staff charted that they were unable to get a blood pressure recording in either arm or leg from 8:30-10:15am despite trying multiple machines (Monk, 2002; Solidline Media, 2010).

At noon, while staff were having difficulty attempting to draw blood, Lewis became unresponsive. Helen called for help and Dr. Murray arrived to the room (Monk, 2002). A code was called and the on-call physician, Dr. Adamson, arrived and subsequently attempted to resuscitate Lewis for an hour before calling a time of death at 1:23pm (Kumar, 2008; Monk, 2002). An autopsy later revealed that Lewis Blackman died from internal bleeding caused by a perforated ulcer with close to three liters of blood and digestive fluid in
his abdomen (Monk, 2002). Ethics and Relation to Nursing 1.75 of 2 points accrued

The nurse has a moral obligation to do good and avoid harm to the patient (Westrick & Dempski, 2009). While not intentional or direct, the nurses caring for Lewis Blackman failed to uphold certain aspects of their standards of care and duty which resulted in his continued decline in heath and eventual demise. Inadequate weekend staffing may have played a part, but the autonomy of Lewis’ mother was removed when truthful information was withheld, or not properly disclosed, by both health care providers and nursing staff (Westrick & Dempski, 2009). The Institute of Medicine (IOM) (2004) reports that among healthcare providers, nurses are most likely to both prevent and identify complications therefore activating appropriate responses in a timely manner. This is often referred to as “rescuing” the patient from complications (IOM, 2004). Unfortunately in this case, nursing care fails to meet appropriate standards of care.

The nurses caring for Lewis Blackman fell short in several ways including: inadequate assessment of the patient, inadequate training for the assignment, and inadequate communication (Westrick & Dempski, 2009, p. 23). Most of these areas are related to failures in the nurses’ independent legal duty to the patient to make an accurate, thorough assessment. If concern or deterioration in condition is noted, nurses have to exercise this independent duty to investigate and utilize the chain-of-command when the nurse reasonably believes harm will result by following orders (American Nurses Association [ANA], 2001; Westrick & Dempski, 2009). The nurses caring for Lewis should have known the physicians’ orders and plan were incongruent did not match up with their assessments, the patient’s complaints, or and his mother’s concerns.

The patient suffered harm from their inaction and they placed themselves at risk of being held liable under this duty (Westrick & Dempski, 2009). In addition, while not qualified to resolve disputes regarding diagnosis or treatment, nurses have a duty to be a patient advocate and to know self-limitations (Hanks, 2008; Hewitt, 2002). Westrick & Dempski (2009) note that the “standard of care does not change for an inexperienced nurse” (p.25), if the oncology nurses caring for Lewis were not comfortable caring for him they should have taken steps to avoid harm such as an assignment change or supervisor guidance (ANA, 2001).

Finally, coinciding with the duty to the patient for a proper assessment, it is a nursing responsibility to communicate effectively. Failing to notify the physician of changes in patient’s condition, inadequate documentation, or failure to utilize the chain-of-command in situations where injury may occur are all aspects of inadequate communication (Westrick & Dempski, 2009). Another prominent issue is a complete failure of these nurses to advise their nursing supervisor of the inadequate physician response when there was concern for the patient’s condition. Documentation was charted noting severe alterations in his condition, but the responses were not adequate or incongruent with his needs (Solidline Media, 2010).

Legal Issues and Relation to Nursing 1 of 1 point accrued
The Legal Information Institute (2014) defines ethics as the interaction among individuals and the nature of duties that people owe themselves or one another. Though the law will frequently represent ethical principles, law and ethics are not always in agreement (Legal Information Institute, 2014). Public law is defined as the sum total of rules and regulations by which society is governed and it is not restricted to simply codifying social norms (Legal Information Institute, 2014; Westrick, 2014). This translates into highly detailed, enforceable codes of conduct found within the health care system that effect judgments regarding conduct of health professionals during litigation (Legal Information Institute, 2014). Failure to fulfill the conduct directed by professional ethics will commonly result in sanctions, or even expulsion, from the health profession (Legal Information Institute, 2014).

Laws Governing Care of Lewis Blackman 1. 75 of 2 points accrued Analysis of the Lewis Blackman case reveals that several laws regarding duties to the patient were not followed. Unfortunately, this breach resulted in the death of a child and a life altering crisis for his family. Laws governing Lewis’ care include: safe medication administration, patient safety, accurate documentation, and reporting (Westrick & Dempski, 2009). These laws apply directly to nurses and other trained professionals in the hospital settings as outlined by the state boards for nursing and medicine (Westrick, 2014). Failure to follow any of these may lead to a malpractice action claim, disciplinary action, or criminal indictment action (Westrick & Dempski, 2009). An important principle of medication administration and patient safety is to question any orders that may constitute a serious risk to the patient (Westrick, 2014). Under state and federal laws, strategies such as standardized handoff communications, direct bedside patient rounds at shift change, and a non-punitive reporting system of errors or near-misses are required as measures to increase patient safety and reduce errors (Westrick, 2014).

Healthcare professionals working in a hospital setting have a legal duty of care noted by the National Council of State Boards of Nursing (NCSBN) and their respective state regulating boards. Failure to rescue, or not responding in a timely manner to serious complications or changes in patient condition, may result in legal actions (Westrick, 2014). The providersThe providers caring for Lewis had a legal duty to document provide their objective assessment documentation including his response to their interventions (Westrick, 2014). Licensed providers should not include subjective comments and assumptions about the patient or family in documentation, but discounting Helen’s subjective view may have constituted an error in professional judgment (Solidline Media, 2010). State Law 2 of 2 points accrued

Licensure for healthcare facilities and health professionals, as well as laws determining healthcare and medical malpractice, are largely regulated on a state level (American Nephrology Nurses Association [ANNA], 2014). The licensed personnel who cared for Lewis are also held accountable for their actions based on professional guidelines (ANNA, 2014). Nurses are accountable under the American Nurses Association (ANA) Scope and Standards of Practice, the ANA Code of Ethics, and their state’s nurse practice act (Westrick & Dempski, 2009). In addition, healthcare providers must follow policies and procedures outlined by their employer. For example, the Montana Code Annotated (MCA) and the Administrative Rules of Montana (ARM) set out requirements and expectations of both nurses and healthcare facilities. Nurses shall “collaborate with other members of the health team to provide optimum client care,” and “consult with nurses and other health team members and make referrals as necessary” (Administrative Rules of Montana [ARM] 24.159.1205).

Regarding the conduct of nurses the ARM (24.159.2301) states: Unprofessional conduct is determined by the board to mean behavior (acts, omissions, knowledge, and practices) which fails to conform to the accepted standards of the nursing profession and which could jeopardize the health and welfare of the people and shall include, but not be limited to, the following: (a) failing to utilize appropriate judgment in administering safe nursing practice based upon the level of nursing for which the individual is licensed; (b) failing to exercise technical competence in carrying out nursing care; (c) failing to follow policies or procedures defined in the practice situation to safeguard patient care. Nurses in the Blackman case did not appear to assess the patient adequately, use good judgment, or consult and collaborate with doctors to intervene in a timely manner in order to ensure optimum care (ARM 24.159.1205). These failures could can be construed as negligence on the part of the nurse. Other members of the health care team, such as the doctors or residents involved in his care, are accountable in a comparable way. Federal Law 2 of 2 points accrued

In the US, hospitals must adhere to many federal regulations in order to stay in compliance. The Center for Medicare and Medicaid Services (CMS) Regional Office and the Department of Health and Human Services (DHHS) run survey agencies in each state that follow guidelines laid out in the CMS State Operations Manual (Center for Medicare and Medicaid Services [CMS], 2013). These guidelines are specific and address any facility failures to adhere to the Medicaid Conditions of Participation (CoPs) and Conditions of Coverage (CfCs) (CMS, 2013; Department of Health and Human Services [DHHS], 2012). After the state survey agency determines how all whether requirements are met, a Statement of Deficiencies form is submitted and the facility responds within which allows 10 calendar days of receipt with for the facility to respond with a Plan of Correction (PoC) to address any shortcomings (CMS, 2013).

In regard to the Lewis Blackman case, MUSC has potential for fault in not meeting CoPs related to safe care. One of the complaints expressed by Lewis’s mother was related to the lack of an adequate informed consent process and the lack of response to requests for treatment when her child was in distress (Solidline Media, 2010). An example of a A provision that could be the subject of this MUSC deficiency related to patient’s rights states: The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. (Condition of participation: Patient’s rights, 2012) Federal requirements for hospitals are also regulated through accrediting bodies such as the Joint Commission, a CMS approved independent, non-profit certification and accrediting organization (Zhani, 2014).

The Joint Commission (2014) evaluates health service providers based on CMS guidelines along with reportable quality, outcome, safety, and accountability measures. This assessment is also based on the Specification Manual for National Hospital Inpatient Quality Measures and the Specification Manual for Joint Commission National Quality Core Measures (The Joint Commission, 2014). The oversights in the Blackman case could be evidence of a breach of patient safety, a breakdown of communication, and a lack of follow-through on the part of the hospital and its staff (Solidline Media, 2010). The accreditation of the hospital is placed at risk due to the potentially negligent acts previously outlined in this case. Components of Medical Malpractice 2 of 2 points accrued

In order to be found liable for medical malpractice, four specific elements must be evident including: an established duty, breadth of this duty, causations, and damages (Bailey, 2013). The court must first determine if there is an established duty to the patient (Bailey, 2013). Usually, a duty of care is set forth in the physician-patient relationship and can be established when a patient seeks assistance from a physician and the physician agrees to treat the patient (Bailey, 2013; Sanbar, Gibofsky, Firestone, & LeBlang, 1995). This relationship can be established through an express or implied contract, reliance, or payment (Bailey, 2013, p.114). In the case of Lewis Blackman, duty was established when Lewis and his parents sought care for his pectus excavatum and consented for a surgical repair (Solidline Media, 2010).

The next element of a negligence claim must show breach of this established duty by demonstrating that the medical provider did not give provide the appropriate standard of care (Bailey, 2013). Standard of care does not have a uniform model and varies, but it may be measured from state laws and national organizations such as the Joint Commission (Janes, 2011). There are standards which a surgeon such as Lewis’
physician must uphold, as well as standards for nursing staff and hospitals. It, and it appears as if a breach of professional standard of care is evident within this case. Finally, the patient must prove establish that the provider’s breach of duty caused otherwise avoidable damages or injury for which the patient should receive compensation (Sanbar et al., 1995). Lewis’ unexpected death was the result of a perforated duodenal ulcer, hemorrhage, and circulatory collapse (Solidline Media, 2010).

In this case: failure to consider the inappropriateness of continued Toradol administration, failure to order simple lab tests that would have detected blood loss, and failure to communicate Lewis’ deteriorating condition to the attending surgeon all appear to contribute to his untimely death. In ____ state, the law states that when harmed, damages such as financial compensation are warranted. As noted above, all four elements of medical liability can be established in the Lewis Blackman case. Lewis’ family and MUSC agreed on an out of court settlement of did settle out of court for $950,000 before filing a lawsuit (Center for Justice and Democracy, 2014). The Blackman family is using this money for scholarships and to fund patient safety initiatives in South Carolina (Center for Justice and Democracy, 2014). Ultimately, this tragedy has become a conduit for change and helps to promote a safe and just culture within healthcare. Implementation of Safe and Just Culture

The report To Err is Human released in 1999 by the Institute of Medicine highlighted the alarming rates of medical errors and sounded a call to action to address the way we deal with errors (Westrick, 2014). In the past, a culture of blame focused on individual accountability with little thought given to analysis of the factors leading up to the error (Westrick, 2014). This blame culture breeds distrust when people blame each other to avoid being disciplined, resulting in a lack of innovative ideas and personal initiative because people do not want to risk being wrong (Khatri, Brown, & Hicks, 2009). In fact, this culture has been blamed for unacceptable high rates of medical errors (Khatri et al., 2009). In a just culture environment the focus is on identifying and addressing the issues that lead individuals to practice unsafe behaviors as well as maintaining individual accountability (Miranda, Samuel, & Olexa, 2013).

Instead of an environment ruled by individual blame, a just culture supports open dialogue to facilitate safer practices (Khatri et al., 2009). In the case of Lewis Blackman, it is evident that communication was an issue on many levels and the principles of just culture were not at work (Solidline Media, 2010). In a blame culture, medical residents are reluctant to question attending physicians and nurses are hesitant to challenge either one in regards to their respective care plan or orders (Khatri et al., 2009). Lack of open dialogue among staff at MUSC perpetuated the belief that assessments of Lewis suffering from “gas” were correct (Solidline Media, 2010). Khatri, Brown, and Hicks (2009) describe a culture of “psychological safety”. Perhaps if this environment was fostered at MUSC the nurses who had concerns would have questioned the prevailing assessment of Lewis and, in fact, saved his life. Furthermore, just cultures look at system issues and may have addressed the unsafe practice of placing pediatric surgical patients on the oncology floor; admission to this unit contributed to before it caused the type of harm evident in the Lewis Blackmans case.

Medication administration is another system that can benefit from a just safety culture. If early warning systems had been in place alerting providers to the hazards of medications, such as giving Toradol to patients with low urine output, maybe Lewis would not have continued to receive this medication that caused him such grievous harm. Just culture recognizes the complexity of errors and encourages patient safety by taking a systematic approach to error prevention (Westrick, 2014). Another key element of just culture is in its desire to treat near-misses with the same level of scrutiny that actual errors receive. Within the blame culture, errors causing no harm are often ignored or dismissed which enables the errors to happen again and eventually results in harm that could have been prevented (Burhans, Chastain, & George, 2012). Instead, error disclosure systems seek to improve quality through education and integration of all relevant parties in the healthcare system including patients and their families (Liang, 2002).

Physicians should be educated about the systems nature of error and patients also must be informed about what they can contribute to a safe delivery environment (Liang, 2002). Patients should be equal partners in the delivery of care and be equipped to speak up when they see mistakes or problems with their care (Liang, 2002). If there had been an error disclosure system within MUSC that clearly outlined patient and families rights and responsibilities, Helen may have had access to the help she needed for Lewis. Furthermore, when the institution realized errors occurred that resulted in a child death, effective policies around error disclosure should have involved the family in the process of investigation and resolution (Liang, 2002). At the outset, an apology would have validated the pain and suffering of the family and may have reduced the risk of litigation, if the family had been allowed to vent and be heard (Liang, 2002). The Lewis Blackman story is full of examples of a system that failed to keep him safe.

A culture of blame that focuses on one individual will not address the changes that need to be made to the system. A just culture creates the hope that errors can be reduced through equal involvement and commitment by every member of the healthcare team to systematically appraise delivery of care (Liang, 2002). A thorough error disclosure system can capture errors when they are near misses, not tragic deaths, and can empower patients to be equal partners in the process (Liang, 2002). Lessons learned from the Lewis Blackman case and application of a just culture environment to medical practice has the potential to make healthcare delivery processes safer. Recommendations for Change in Advanced Nursing Roles 1 of 2 points accrued

The goal of any healthcare delivery system is to provide safe and comprehensive patient care. According to Mason, Leavitt, & Chaffee (2012) nurses are well positioned to reform healthcare in ways that promote increased public health and reduce healthcare costs (p.10). Nurses, especially advanced practice nurses, must evolve in their roles in order to provide high-quality, patient centered care and to implement techniques that facilitate necessary changes within their institution. Transforming care at the bedside is a technique that empowers nurses to initiate improvements in four main categories including: safe and reliable care, vitality and teamwork, patient-centered care, and value-added care processes (Mason, Leavitt, & Chaffee, 2012). Similar to a just culture framework, this contemporary program is an integral part of a nursing effort that focuses on improvement of hospital work environments in an effort to improve nurse satisfaction and ultimately the quality of patient care (Mason, et al., 2012).

The work atmosphere improves as staff deliver care in safer, better operating systems where the culture encourages quality and safety over punishment and blame (ANA, 2010). Nurse practitioners, and other advanced nurses, already integrate evidence-based practice with caring, compassion, and intuition to provide quality care (ANA Nursing Standards, 2003). Their role as patient advocate will now help to removes barriers, facilitates faced in achieving optimal healthcare and assists in the development of delivery environments focused on patient safety and a just culture (ANA Position Statement, 2010; Mason et al., 2012).

In addition, incorporating technology into the art of caring will allow nurses to be resourceful and responsive to challenges of the complex health care system (ANA Nursing Standards, 2003). Continued learning, participation in civic activities, membership and support of professional associations, collective bargaining, and workplace advocacy will strengthen individual practice as well (ANA Nursing Standards, 2003). The occurrences of medical mistakes should be viewed as opportunity to learn and improve nursing efforts as advanced practitioners. Conclusions 1 of 1 point accrued

Healthcare professionals have to be diligent and meticulous when caring for every individual. They are trusted to do good and avoid harm (Westrick & Dempski, 2009). Medical errors caused by poor clinical decision making or negligent actions can cause significant damage to patients, families, and institutions as well as the medical providers themselves (Wu, 2000). The Lewis Blackman case is an unfortunate example of a critical breakdown within the healthcare delivery system that resulted in the death of a promising youth (Kumar, 2008). Failures among the MUSC medical providers’ established ethical and legal duties of care culminated to satisfy all four qualifications for malpractice liability (Sanbar et al., 1995; Westrick & Dempski, 2009). Following through in situations where there is concern for the patient’s best interest will help to avoid any compromise on patient safety. This not only prevents negligence, malpractice, and disciplinary or criminal action, but also injury or serious adverse outcomes (Westrick & Dempski, 2009).

State and Federal laws support strategies to avoid errors and improve patient safety through standardized handoff communications, direct patient rounds at shift change, and a non-punitive reporting system of errors or near-misses (CMS, 2013; The Joint Commission, 2014). Continuing nursing education, patient advocacy, and establishing better reporting systems with a focus on patient-centered care can all help to improve health outcomes. “By promoting system improvements over individual punishment, a Just Culture in healthcare does much to improve patient safety, reduce errors, and give nurses and other health care workers a major stake in the improvement process” (ANA Position Statement, 2010, p. 7). This culture of patient safety addresses the gaps in traditional healthcare delivery systems and works better with nurses’ critical thinking skills and process (ANA Position Statement, 2010). Advanced practice nurses are well placed to help facilitate a just culture environment and to advocate for improved safety measures (Mason et al., 2012).

References

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