Who killed Lewis Blackman?

I first encountered the tragic yet enlightening story of Lewis Blackman at the beginning of my first year of medical school this past August. It was jolting, disheartening, and frightening – to myself as a future medical provider and as a patient/family member. Today, I felt myself reacting in many of the same ways to his story; again, I was shocked and angry, and again, I reflexively asked myself, why didn’t the nurse do something? The intern? The chief resident? Who could be blamed for Lewis’s unnecessary death?

But wait… This question went against everything I thought I had learned about patient safety. Despite the fact that since my first viewing of this video I read Why Hospitals Should Fly (among a number of other valuable sources) and embraced the idea of a blameless culture in order to foster a transparent and beneficial learning environment, my engrained reaction was to begin pointing fingers. If anything, the hierarchical and tribal nature of the medical profession and resulting system breakdown is to blame for Lewis’s death. The individuals involved are all well-meaning healthcare professionals. These are bad systems – not bad people – that we are tasked to improve, and this is my true belief. And yet, my search for someone to blame was automatically triggered by the gut-wrenching details of Lewis’s decline and eventual death.

My point is this: it is going to take a complete reversal of this mindset, this poisonous attitude, this blame-driven culture to improve our systems and make progress in patient safety. No doubt, it will be difficult, but until we shift to a blame-free, safe environment in which errors are embraced and learned from and all healthcare team members are treated with respect, we cannot be expected to make any progress.