Day 1 Reflections following Lewis Blackwell

I was moved to learn more about patient safety after my mother had an adverse post-operative event in December. To make a long story short (anyone is welcome to talk with me about this in person) she had an internal bleed that was caught late, and then once caught was mistakenly not addressed. She bled in her hospital bed for nearly 2 days, her blood pressure dropped to 75/59 and her hemoglobin was 5.2 g/dL before nurses overstepped the physician and took action themselves. She received 8 units of blood during her recovery. Watching the case of Lewis Blackman I was struck by how many similarities were between his case and my mothers:

  • Lewis case occurred over a weekend, my mother’s over Christmas break
  • she suffered an internal bleed in the hospital, missed right in front of everyone
  • They minimized Lewis issues as “just” constipation, I had a surgeon come in and tell my mom it was “just” some post-operative oozing
  • Patient handoff and miscommunication errors played roles in both
  • I felt guilty for being the one who talked her into getting this elective procedure done
  • The nurses on our floor KNEW something was wrong but no one never let on
  • The above made it feel like the hospital staff was lying to my family
  • My family just had a gut feeling that something was wrong, but we also didn’t know how to get help. We were also confused about who exactly was in charge of my mother’s care.
  • Helen said, “we just hunkered down until help could arrive” and I remember a time where I trusted the staff so little I pulled my step-dad into the hall and told him “you do not let anyone touch her or do any procedure until someone arrives that can tell us what’s going on”

As many similarities as there were between Lewis and My mother’s case, there was one factor that made all the difference: The Nurses.

My mother’s nurses were so attentive to her, when they felt something was wrong they took it upon themselves to watch her extra close, and they ended up being the ones who discovered the issue and eventually placed orders themselves for imaging and blood. I am so thankful that someone in my mother’s health care team took accountability and action. It terrifies me to think what the outcome could have been otherwise.