After watching the Lewis Blackman film, I was surprised when I learned how many mistakes were made during his hospital stay and how many people were involved.  How did no one say anything day after day of the patient not getting any better and then actually getting worse?  As a nurse, I was especially upset with the lack of advocacy by Lewis Blackman’s nurses.  Nurses are with their patients at the bedside all day.  They should be able to recognize small changes in the patient’s condition.  When one of the nurses noticed that something didn’t seem right, nothing happened.  Was anyone notified of her findings?  Although it can sometimes be intimidating to go up the chain of doctors, nurses and residents should do it if they are worried about their patient and they feel their concerns are being ignored.  One of the topics we discussed today was not wanting to ask for help for fear of being bullied.  This culture needs to change.  There is no reason to risk a patient’s life and safety because someone is afraid to speak up.