As I watched Lewis Blackman’s story unfold before my eyes on the screen at the front of the room, I found myself becoming angry. How could this 15 year old boy be dying? He entered the hospital for a minimally invasive procedure and I’m sure the last thought on his and his family’s minds was that he would never step outside again. As I watched his heart rate increase, and his abdominal pain worsen, and then his blood pressure drop until it was no longer detectable, I was screaming on the inside, “why has no one scanned his abdomen?! He is bleeding into his abdomen!” I did not know why he would be bleeding into his abdomen when he had surgery on his chest wall (I didn’t know ketorolac can cause GI bleeds), but the developing clinical picture seemed to fit that diagnosis.

When one physician writes a statement in their note, whether it’s a presumptive diagnosis, part of the patient’s history, or a physical exam finding, when other health care professionals caring for the patient read the note, they assume its contents to be true. When one doctor wrote in their note saying Lewis’ abdominal pain was due to constipation, many other people followed suit without performing their own critical thinking and coming up with their own differential diagnosis. Critical thinking is key to patient safety. If the presumptive diagnosis doesn’t fit every part of the clinical picture then think outside the box…what else could be causing this patient’s symptoms? Part of being a leader in patient safety is to not just copy someone else’s thoughts from their note, but to perform your own physical exam and synthesize your own differential diagnosis and to then have the courage to speak up to the team. Although there are many unfortunate factors that fell into place and lead to Lewis’ death, known as the swiss cheese effect, maybe one way this could have been prevented is by other healthcare professionals not jumping on the constipation bandwagon and instead brainstorming another etiology of Lewis’ symptoms.