Where did the system fail lewis and his family

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Reference no: EM133251753

Case Study - The Lewis Blackman Hospital Patient Safety Act - It's Hard to Kill a Healthy 15-Year-Old.

Questions -

1. Where did the system fail Lewis and his family?

2. What were the system failures in Lewis's case process related to:

a. Preparations?

b. Organizations?

c. Environment?

d. Technology?

e. work tasks?

f. Healthcare providers?

3. Where in the process of care did incidents (errors, near misses, adverse events, and harm) occur?

4. What would be the elements of a more transparent informed consent process?

5. Were there opportunities in the process of care to repair physical damage? relationship damage? emotional damage?

6. What aspects of this incident will the new legislation cited in the care address? Which aspects does it not address and what else should be done to prevent recurrences of such incidents?

7. If the nurses and residents had checked the references (PDR, for example) for ketorolac, what would they have found and how might it have affected Lewis's treatment?

Share an example of medication administration safety measures you have worked with in a health care or clinical setting. Were the systems effective? What are your suggestions for improvement?

Reference no: EM133251753

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