Blackman Case Analysis
Action Taken in Lewis’ Case
In the case of Lewis Blackman, the 15-year-old boy who died following complications from elective surgery, several actions were taken. Initially, Lewis underwent a laparoscopic procedure to correct a chest abnormality. However, after the surgery, he started experiencing complications such as bleeding, vomiting, and a high heart rate. Despite these signs, his doctors failed to accurately diagnose the severity of his condition, and Lewis was not transferred to a higher level of care. Additionally, the hospital nurses failed to recognize and report critical information to the treating physicians. This led to a delay in diagnosis and treatment (Lundereng et al., 2020). Other problematic actions include the lack of communication between medical staff, inadequate monitoring of Lewis’ vital signs, and a failure to escalate his care to more experienced physicians. Ultimately, these actions resulted in Lewis’ death, highlighting the importance of proper communication, teamwork, and clinical decision-making skills in healthcare.
Appropriateness of Actions Taken
The actions taken in the case of Lewis Blackman were not the most suitable, as they led to his unfortunate death. Multiple factors contributed to the poor decision-making process in the provision of healthcare services to Lewis. The healthcare providers failed to recognize the severity of his condition. They also did not transfer his case to a higher level of care. Moreover, there was a lack of communication and coordination among the medical staff. This led to delayed diagnosis and treatment. This brings to light the importance of teamwork and effective communication in healthcare settings (Morrell et al., 2020). Furthermore, a lack of adequate monitoring of Lewis’ vital signs further compounded the situation. Proper monitoring would have allowed for early detection of complications, leading to timely intervention and a better outcome.
Another mistake was the failure to include Lewis’ family’s input when making decisions. All their concerns and observations were disregarded. This further emphasizes the need for a patient-centered approach in healthcare. All patients and their families are considered valuable members of the healthcare team. All in all, the actions taken were not appropriate, and the healthcare provider’s failure to prioritize patient safety ultimately led to the young man’s death.
Consequences
The actions taken in this case had very severe consequences. Lewis’s death resulted in a profound impact on his family and friends. They lost a beloved son and friend. The case also brought to light the shortcomings of the healthcare system and the need for improved patient safety (Carayon et al., 2020). The hospital and healthcare providers faced legal and financial repercussions following the incident. The hospital was found to have violated regulations. The healthcare providers involved in Lewis’ care faced disciplinary action. Additionally, the family established a foundation to promote patient safety and prevent similar incidents from happening in the future. Furthermore, the case led to significant changes in the healthcare system. This included the implementation of electronic health records, increased emphasis on communication and teamwork, and the establishment of guidelines to ensure patient safety. The case served as a wake-up call for the healthcare system, highlighting the need for improved patient-centered care and patient safety protocols.
The consequences of the actions taken in Lewis Blackman’s case were significant. Notably, they resulted in the loss of a young life and legal and financial repercussions for the healthcare system. They also led to the implementation of changes to improve patient care and safety. The incident serves as a reminder of the importance of patient-centered care, effective communication, and collaboration in healthcare.
Omissions
In Blackman’s case, several factors were not considered, thus leading to the tragic outcome. First, the providers did not take into account Lewis’ family’s input when making decisions, disregarding their concerns and observations. The family had observed several concerning symptoms, such as Lewis’ high heart rate and difficulty breathing. These were not adequately addressed. If the healthcare providers had considered the family’s input, they might have detected the severity of Lewis’ condition earlier and directed his care accordingly.
Moreover, there was a lack of standardized protocols and guidelines for patient care. This created inconsistencies in the care practices of the medical team (Rangachari & Woods, 2020). The providers did not follow established protocols for monitoring vital signs and intensifying care when necessary. This led to delayed intervention and inadequate treatment. Additionally, there was a lack of communication and organization among the healthcare team, leading to misunderstandings and incomplete information transfer. Furthermore, the providers did not adequately assess Lewis’ health condition before surgery. Lewis had a history of asthma, which was not taken into account during the preoperative evaluation. The lack of a comprehensive evaluation might have contributed to the complications that Lewis experienced during and after the surgery.
Compliance with Current Practices in Global Health
The actions and procedures taken in this case were not in line with current theories, practices, or policies in global health. The case highlighted several gaps in the healthcare system and the need for improved patient safety protocols. The World Health Organization (WHO) has established guidelines and recommendations for patient safety (Diaz-Navarro et al., 2021). These guidelines stress the importance of effective communication, patient-centered care, and teamwork in healthcare. These guidelines were not adequately followed in Lewis’ case, leading to a poor decision-making process and delayed intervention. Furthermore, the case highlighted the need for standardized protocols and guidelines for patient care. The lack of consistency in care practices and the failure to follow established protocols led to inadequate treatment and delayed intervention. The WHO has also established guidelines for surgical safety, emphasizing the need for a comprehensive preoperative evaluation, proper monitoring during surgery, and postoperative care. These guidelines were not adequately followed in Lewis’ case, leading to complications and adverse outcomes.
References
Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M. (2020). SEIPS 3.0: Human-centered design of the patient journey for patient safety. Applied ergonomics, 84, 103033. https://doi.org/10.1016/j.apergo.2019.103033
Diaz-Navarro, C., Leon-Castelao, E., Hadfield, A., Pierce, S., & Szyld, D. (2021). Clinical debriefing: TALK© to learn and improve together in healthcare environments. Trends in Anaesthesia and Critical Care, 40, 4-8. https://doi.org/10.1016/j.tacc.2021.07.004
Lundereng, E. D., Dihle, A., & Steindal, S. A. (2020). Nurses’ experiences and perspectives on collaborative discharge planning when patients receiving palliative care for cancer are discharged home from hospitals. Journal of Clinical Nursing, 29(17-18), 3382-3391. https://doi.org/10.1111/jocn.15371
Morrell, B. L., Eukel, H. N., & Santurri, L. E. (2020). Soft skills and implications for future professional practice: Qualitative findings of a nursing education escape room. Nurse Education Today, 93, 104462. https://doi.org/10.1016/j.nedt.2020.104462
Rangachari, P., & L. Woods, J. (2020). Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers. International journal of environmental research and public health, 17(12), 4267. https://doi.org/10.3390/
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Question 
The tragic death of Lewis Blackman can be understood in the context of errors in decision-making. Write a three-page case analysis focusing on the list of prompts below. An important part of your response should include an analysis of the situation and a thorough identification of issues/actions described in the case that may be problematic.
Blackman Case Analysis
Focus the analysis on the following:
What actions were taken in the case?
Were these actions the most appropriate, and why?
Were there any consequences of the actions taken?
Was anything omitted or not considered?
Were actions/procedures in line with existing codes of practice, policy, or theories in global health?
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