They Should Have — Reflections From Day 1 at #TPSER8

Watching today’s video about Lewis Blackman’s story elicited emotional reactions from just about everyone in the room.  Personally, I felt a combination of frustration, dread and sadness throughout the film. It was clear to everyone that faulty assumptions, lack of communication, and a refusal to look at the situation objectively lead to Lewis’s unnecessary and very tragic death.

Because many of the problems were so glaring, my initial reaction was simply to say, ”well, the nurses simply should have called the doctor,” or ,”the resident should have listened to the mother.”  In the aftermath of such inadequate medical care, the problems look so simple, and saying “they should have” sounds like it makes sense.   And while it’s true that a more attentive resident or a bolder nurse could have saved Lewis’s life, I don’t think that’s the real issue.  Rather, what stuck with me all day was wondering what led the residents and nurses to act in the way they did, and what aspects of their training, work environment, professional relationships and many other components could be changed in order to alter their behaviors.

I wanted to get angry at the resident or even punish him for being so cavalier, but I know that’s not the right response.  Instead, what if we sat down together as a group and really tried to dissect the story and understand the core elements that comprised each error along the way.  Let’s brainstorm together and see if we can narrow down what truly caused the mistakes.  That way, instead of saying they should have, we can devise appropriate and precise solutions that reflect the true components that led to each error.

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