Today I went in with an open mind not knowing what I would learn. I left with a great sense of new knowledge along with a strong desire know more. When I came back to my room, I found myself looking up random related areas, including how Leapfrog scores are calculated, founding of QSEN, and psychological safety assessment instruments. The Lewis Blackman video was heart wrenching to watch. There were many important points regarding the chain of events and how the situation was handled. One of the things that struck me the most were the comments Cathy made after film. She talked about some of the underlying reasons why the family had decided to go ahead with the surgery (father’s experience with bullying, etc.) along with the impact Lewis’ death had on the family. Lisa also alluded to this point with her personal story. It really hit me of how many secondary losses and challenges that arise as the result of one medical error along with the fact that we should not assume anyone’s underlying reasons for wanting treatment or not complying with a treatment plan. Whole families are changed forever, which impacts their future abilities to live their lives to the fullest. In my experience, patients’ loved ones are often left behind without adequate knowledge, resources, or support. If we are expecting the patients’ loved ones to be extra sets of eyes and ears we have to give them the tools and resources that can properly support them as it puts a tremendous responsibility of their shoulders on top of the emotional toll of seeing someone you love go through a serious illness or injury. I am not sure how we best do this in our already very jam packed schedules, but I strongly believe we need to do more than we currently do as it is taking a toll on millions of families in all areas of the country. We need to find ways to work with family caregivers to include them as part of our team rather than thinking of them as the crazy wife or hysterical mother as at that point we have discounted their perspective as less than ours, which sets up a scenario for higher safety risks.