Medication Safety: A Patient's Story
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- Опубліковано 5 вер 2012
- Helen Haskell, the founder and president of Mothers Against Medical Error, shared the story of her son, Lewis Blackman, at the conference "Improving Medication Safety Through Effective Communication and Teamwork."
Patient safety experts have long agreed that medication errors are the single most frequent source of preventable error. Additionally, creating a culture of patient safety requires strong teamwork and effective communication between healthcare providers, yet there is often not enough attention devoted to developing these skills.
The NYC Health and Hospitals Corporation (HHC) and CIR's Policy and Education Initiative (PEI) sponsored the one-day conference on November 30, 2011, bringing together 160 healthcare professionals from all 11 hospitals in the HHC system. The conference focused on a team and systems-based approach to reducing medication errors, with emphasis on the use of opioid and effective pain management. It was co-sponsored by 1199 SEIU and funded by the Federal Medication and Conciliation Service and the CIR Patient Care Trust Fund.
Learn more at cir.seiu.org/policy
I'm in tears watching this for my first semester of nursing school.
Maybe it’s time to choose a different career path 😊
same here
I watched this as part of my 1st Semester in Nursing School. No textbook could have taught me better to conform my care to the patient and not the patient to the care plan. I honor you and thank you.
"Lack of respect for medications" is exactly right. This is a powerful video.
We talk about this case, and what happened to your son in the first class in our nursing program. I am confident that Lewis' story will have a lasting impact on each of these future nurses and perhaps save lives in the years to come. Thank you.
I watched this video as a part of my BSN course and it made me cry... It is so so sad, and could have been avoided if clinicians actually paid attention to their patients...May he rest in peace..
I am an occupational therapy student in a grand rounds class. We were shown Lewis’s story about patient safety and error reduction. His story is still being told. His story will continue to be told. While I am not authorized to prescribe medication, I will be diligent in reviewing medical records to try to recognize errors inputted either by myself or others on the healthcare team. May Lewis Rest In Peace, and may you find comfort knowing that your child’s story will help to save other lives.
Such a touching tragic story.. we are all learning from stories like yours. Peace to you.
These stories I have been reading are nearly unbelievable. I have been a nurse for thirty years, most of it in critical care. I weep for the future of healthcare in America.
As do I
I will be showing that to the students in my Fundamentals of Nursing Medication Administration unit. How powerful the message is.
This is why more nurses are needed. Medication and other medical errors happen because 1 nurse has way to many patients to safely take care of. American hospitals please hire more nurses! It’s not like you wouldn’t be able to find more nurses as there are plenty out there not practicing nursing because there are more nurses than there is nursing jobs.
i am so sorry for ur lose this is devastating
Wow. this is very sad.I keep searching for answers through other parents who have experienced the loss of a child. My son Andrew passed away on July 4th 2016. I was told very little so I just assumed he was fine when he went to the hospital in Nov (2015) but he remained in multiple facilities over the course of those next eight months. After obtaining medical records (after becoming the administrator of estate) in Nov (2016) I found out just how much he had actually endured. Things that I HAD NOT BEEN TOLD.. I commend you. Andrew was 26.
I went through this story and it touched my heart. I would do everything possible to saves life.
I'm so sorry for the pain and suffering Lewis and your family experienced as a result of this situation. It is truly tragic. I thank you for sharing this painful story as a means to implore to the nursing community and healthcare professionals that listening to patient's is paramount in providing quality care. I believe in questioning orders and and advocating for a provider to see a patient vs. waiting for them to show up and continuing with whichever orders are in place while patients aren't improving or expressing concern. I've been able to use my clinical experience and expertise to support this advocacy and I support nurses asking questions and advocating for knowledge and patient safety to build their individual practice. It takes time and the support of experienced professionals to mentor new nurses on how to develop assessment and listening skills which will increase positive patient outcomes.
Oh dear l was a bureau RN at the time. I listened to the patient. He yelled at me while l was at the correct patient beside. He claimed he was the patient l was to administer heparin. The correct patient said that he was the patient that was to receive the medication. I stood stocked in my boots and went directly to the patient who yelled at me and administered the heparin. I could have killed them myself with my bare hands for lying to me both men. I reported the incident. From then on when l am in a room of just men. I check their wrist bands and check verbally. It took a while to be unnerved by men.
God Bless you and your family for sharing this story. I am a nurse and this is one of my biggest fears!!!! I hope that I will not be one of these people and that I can continue to be very aware of medications that I give! My deepest sympathies to you, your family and Lewis.. May God comfort you and yours. Thank you for sharing!!!
the video is touching, it reveals how nurses are unwilling to assist one another in caring for each others patient except theirs and how too much of application and reliance on guide and protocol cause neglect of patient symptoms.
This is such a sad story. I wish every RN would be a true patient advocate, rather than just follow protocol. The moment his renal output fell below 30cc's/hour he needed a full assessment to be performed and adjustments to be made. NSAIDs can be such nasty drugs... causing ulcers, renal & hepatic failure, yet everyone uses them like candy. Such a tragedy.
It's sad that that poor boy had to be put through all of that. The professionals, except for the elder nurse, were asleep at the wheel and it proved bad for the boy.
Unfortunately physicians disregard nurses due mostly to pride. You can do your best to advocate but when a physician doesn’t seem to care you begin to doubt your assumption.
the sweating itching and throwing up are classic signs of overdose on opioid painkillers
Nurses need to work as a team. Doctors should be acknowledged more in this case. I am bewildered why this patient was not seen by the specialist as was needed to save this young boys life not waiting for an autopsy report. RNs do not have the knowledge as a specialist or doctor. RNs knowledge is learned by experience and ongoing practise. Therefore it is always better practice to report and direct ongoing patient care to the right team members the specialist and doctors.
What type of practitioners and what were their qualifications, who were working on your son?
How can I ask you for your permition to show this video to an audience in a Patients Safety topic?
I am from Mexico and the Patients Safety is a great taboo, the hospital's owners bealive the Patients Safety is a wasted time and money. I have a different point of view and I want to do something different in order to get the power to the people ussing the health mexican services. Thanks so much,,,
Constipation?? How could anyone with a degree believe that based on the symptoms. You can’t just look at someone and assume that someone is constipated. Even so it wasn’t treated. And no attending for 2 days?
how many pt did those nurse have.
It doesn't matter. I've had 12, on shift and none of them went without a thorough physical assessment. None of them conformed to "The Plan" - it was the other way around.
I love how people trust the government when they rather give you deadly doses of medication so you don't feel the pain instead of trying alternatives that work like marijuana.
Medication errors are indeed problematic in the healthcare industry. While there are many scenarios of when these errors occur, it seems that understaffing, distractions, and unclear doctor orders are very high on that list.
abstract on medication errors
Exactly!
Im sad.
i am so angry and upset watching this!
People are fooled by the word minimal.
Any type of surgery is a risk and as nurse I have seen cases where things have gone disasterly wrong even with simple procedures.