의료 오류 예방: 환자 안전 및 치료 개선

환자 안전과 간병인의 대응을 개선하는 것은 의료 사고를 예방하고 의료 서비스에서 치유를 촉진하는 데 매우 중요합니다.

### 의료 오류 예방 및 의료 서비스에서 환자 피해에 대한 대응
* 🏥  의료 전문가의 양심과 의료 오류 발생률
* 👨‍⚕️  의료 분야에서의 의료 오류 및 환자 피해에 대한 교육 동영상 소개
* 📋  루이스 블랙몬의 사례와 의료 서비스에서 정보에 입각한 동의의 중요성
* 🚨  수술 절차, 수술 후 합병증 및 상황의 심각성을 인식하지 못한 경우
* 💔  비극적인 결과와 환자 및 가족과의 솔직하고 개방적인 의사소통의 중요성
* 🔍  루이스 사례의 진단 오류 및 조기 종결
* 💡  의료 서비스에서 마음챙김과 투명성의 필요성
* 💬  정직한 커뮤니케이션의 중요성과 부작용의 여파
* 👩‍⚖️  의료 기관의 책임과 루이스 블랙맨 법의 영향
* 🌟  의료 오류로부터 학습하여 환자 안전과 치료의 질을 개선합니다.

doctors and nurses are the most conscientious people in the world. Most care deeply about their patients, but they're also human than occasionally they make mistakes. Although a lot of progress has been made in reducing errors in the past few years, they still happen too often. Ten years after the Institute of Medicines report to errors healing was first published, we still have a lot of work to do to create a safe health care system. Hello, I'm Luciene Leap, adjunct professor of health policy at Harvard School. Probably health, it is my pleasure to welcome you to the first in a series of educational videos that will address two important issues in healthcare today: prevention of medical errors and how we, the caregivers, respond when our care is caused harm to one of our patients. Using actual clinical cases, we will share with you errors that have occurred during the provision of patient care. Through open discussion, critical analysis, and reflection on these cases, we will show how you can develop improvements in care so that others do not suffer similar outcomes, how you can change your systems to prevent harm.

it will be a long time before errors are completely eliminated, and when patients are harmed by our mistakes, it can be devastating for them and their families. Not only are they hurt, their trust in us as caregivers is badly shaken. How we respond makes all the difference in the world and how they feel about themselves and us. In a real sense, how we respond defines who we are as individuals and our profession as a whole. Too often, at this time when our patients and their families need us most, we have turned away from them, hiding behind a wall of silence out of fear and shame, or because of bad advice. There is a better way. Open and honest communication between caregivers and their patients and families starts the process of healing and closure for both the patient and the caregiver. In fact, it's the only thing that does. We'll talk about how to do that. The final goal of our educational videos is to inform consumers on how they can take a more active role in their care. Patients and their families can and

should be true partners in their treatment and can provide critical input on aspects of care that we caregivers may miss. The case that's highlighted in our series could have happened in any Health System or to any caregiver. These particular cases were chosen both because they illustrate events that are still too common and because they provide critical learning opportunities for improvement. Our first case involves a young boy, Lewis Blackmon. Lewis' story provides a number of important learning opportunities for caregivers, patients, and their families. As the story unfolds, you can pause the video, discuss, and reflect on what is happening, and think about what could be done differently. We hope that by the end of Lewis' story, you will have a better overall understanding of these important safety issues, how to recognize them, and most of all, prevent them from occurring again. Thank you for taking time to learn more about patient safety and for allowing us to share you. Code Blue Room 5:17, code blue 5:17. We were standing there not knowing anything, not knowing what to think, and then I turn around and there's this man.

at my elbow, and he tells me he's the pastor. And then I realized that something very serious was happening. And he saw in my face one day from 15 p.m. A flurry of medical personnel are rushing to 15-year-old newest Blackmun's hospital room. Something is desperately wrong. Just four days earlier, Luis came to the hospital for elective surgical repair of his pectus excavatum, a congenital chest deformity. Aside from my asthma, Luis's mother wise healthy physically active and gifted young man with an eternal energy. Luis Blackmon is leaving his mark early life growing up. Luis was the boy that all the little girls wanted to marry. The entertained made those around him young and old laugh and smile. A love for learning had been instilled upon Luis at a young age by both his father bar and his mother Helen. In the classroom, Luis transformed that love for learning in ways that were uniquely his own. Teachers described them birth. Luis carries a rope with him. The light in his eye, a unique combination of intelligence.

Susy Azzam and essential goodness, and that people look easygoing, good-natured, and into soccer, acting, science fiction, and the Dave Matthews Band. Louis makes friends easily from all walks of life. He is always eager to expand his circle of friends and often reaches out to the underdog. Louis has a dry sense of humor and quick wit. His sensitivity to others and the world around him comes from a maturity beyond his 15 years. Up until the time the Blackmun's decided to have Louis's condition fixed, surgery for pectus excavatum had been thought to be intensive, and the recovery arduous. However, armed with new information that a new, less invasive procedure had become available, the Blackmun's decided to have the surgery. The following story highlights several important educational objectives. By the end of this film, viewers will be able to: 1. List the benefits of a robust informed consent process as the first step in the delivery of safe and transparent healthcare. 2. Describe how diagnostic errors contribute to patient harm.

define premature closure and appreciate its impact on diagnostic errors for understand why calling for help when uncertain is an important characteristic of safety cultures. Appreciate how empowering nurses and physicians to call for help can reduce patient harm. Additionally, viewers will be able to describe the value of a rapid response process when harm occurs that aims to maintain patient and family trust. Define what transparency means to caregivers, patients, and families. Describe what patients and families expect from caregivers and institutions when harm has resulted from our care and how institutions can meet those expectations. Recognize the importance of incorporating observations and experiences of patients and families into adverse event investigations and process improvements. 6:40 in the morning, Lewis is brought into the operating room. The operation lasts about two hours. A thoracic epidural is placed in the operating room for post-operative pain control, as well as surgical pain will be managed with epidural analgesics. 30 milligrams of intravenous ketorolac to be given every six hours.

Louis's surgeon conveys to the family that all went well. However, in the recovery room, staff are concerned that Lewis has very little urine output due to a lack of beds on the surgical floor. Lewis is later admitted to a pediatric oncology floor. His urine output has still not increased, and he is experiencing nausea and vomiting. We had really never considered having surgery for Lewis's pectus condition until we saw this article in the newspaper talking about a new safe, minimally invasive way to correct this condition. It attracted us. It offered perfection. It offered something that, you know, the wicked we could fix it and give him a much better life because it was they were talking about the promise and not the risk at the very outset. Patients and family should know about the condition that they have. They should be told what the treatment options are, what are the alternatives. They should be told what are the risks, one of the benefits if you're going in for a hospital stay. They should be aware of what is going to happen, what the

procedure will involve what will happen afterward what medications their loved one will be on your Lewis had problems from the moment he entered the hospital. We later found out that he had no urine and his bladder in the operating room, and this was a small problem that was allowed to snowball. Eventually, they just released him to the floor. He still not urinating, and they sent him to the oncology ward rather than pediatric surgery. Louis's first post-operative day progresses better than the day before while still having some chest discomfort, which he reads during the day as a 2 to 4 on a pain scale of 1 to 5. His urine output picks up later that afternoon after his intervenors fluids are increased. His nausea continues, however, and Louis is unable to take any fluids by mouth. His chest pain continues to be managed with epidural analgesics and intravenous ketorolac every six hours. Louis's vital signs are stable throughout the day. Blood pressure is noted to be 100 over 50, and his heart rate around 80 beats.

per minute, his recovery was never easy. He was always sweating, in a constant sweat. He was itching. He was not able to keep anything down, not even water, the entire time he was in the hospital. And one of the ironies of his hospital stay was that in his chart, they kept advancing his diet, so that he was being brought these trays of normal food, which would then be taken away uneaten. No one seemed to be paying attention to what was actually going on with the patient. Patient-centered care is about seeing the person who's in a hospital bed, not the person with the disease or the condition, but who is that person? In the case of Luis Blackmon, who was this 15-year-old boy who was beloved by his parents and his sister, he was a star student, he was an actor in local community theater. Patient Center care is about seeing the person who is that patient. Early Friday evening, Luis's surgeon examines ELISA and tells the family that Luis is progressing well. On Saturday morning, the attending surgeon overseeing

Louis's care for the weekend examines Luis and tells the Blackmun's everything is going well. Vital signs remain stable with a blood pressure of 112 over 56 and heart rates between 70 to 80. Luis is taking sips of water but still has considerable nausea. His surgical chest pain continues to fluctuate between 2:00 to 4:00 on a scale of 5. Luis is still receiving epidural analgesics and ketorolac as staff try to manage his pain. The last time we saw his surgeon who had done his surgery was on Friday, and then Saturday one of the other pediatric surgeons was on call. We had no idea that that hospitals didn't have the same level of care on the weekends or that you know that it really would just be the intern and no one else. So that is something that that patients need to be aware of night and weekend care. Patients and families need to know that they need to be especially vigilant during the night times and on

weekends because hospitals are just not staffed in the way they are during the week. During the day, in the case of Lewis, that the outcome may have been very, very different if he had been seen during the week. If that had happened to say on a Tuesday or Wednesday, the outcome would have been very, very different. We had no idea who anyone was. There were all people in scrubs or white uniforms of one sort or another. We didn't know an orderly from an attending. We had no idea who was who. It was only much later, after I got Louis's chart, that I was able to sort out the junior resident. The entire time I had what's a nurse. Researchers have shown that coverage by a different physician at night was more predictive of hospital complications and errors than was the severity of the patient's illness. A couple of things happen at weekends that make effective care more complicated. There aren't as many people around to cover the same number of patients, so you may have residents who are covering cross

covering other services with patients that they're not familiar with during the week, and if one of those is desperately sick, they need to know about that at the handoff so that the new team is essentially hitting the ground running when it comes to look after the patient. We thought on Friday that we had finally turned the corner because Luis was finally urinating, which was our big concern, so we thought that things would be improving from that on and they seemed to calm down. He still needed increasing amounts of pain medication, but we knew that pain management was difficult for this surgery. At 6:00 a.m. Sunday morning, the nurse arrives with another dose of ketorolac. Lewis is still unable to eat solid food and can barely take liquids. 30 minutes later, Lewis has a sudden onset of severe pain in his upper abdomen and reports obtain score of 5 out of 5. Lewis tells staff the location and intensity of this pain is much different than the surgical pain. Shortly after the abdominal pain

starts Lewis reports he is also experiencing significant pain in his groin and penis. Louis's nurse has alarmed and leaves the room. She returns a few minutes later and tells the family that the abdominal pain is due to gas or constipation. During the morning, Lewis's blood pressure and heart rate increased to 124 over 70 and 111, respectively. Caregivers continue to attribute his abdominal pain to constipation and the penile pain to his Foley catheter. The Foley catheter and thoracic epidural are discontinued. Oral oxycodone is added to the ketorolac for pain management. Lewis's abdominal pain subsides briefly, but by 12:00 p.m., he again rates his pain as a 5 out of 5 and reports the pain is now located in his lower abdomen. The nursing staff recommend Lewis sit up in a chair, take a bath, and he is encouraged to walk around the hospital floor. The nurse wanted him to walk. She got on one side, and I got on the other, and we

held him up by the shoulders and sort of half dragged him around the ward, and every three steps he would have to stop and lean on my shoulder because he just couldn't do it. She didn't seem to see anything wrong with us. Lewis's abdominal pain continues throughout the afternoon and into the evening. At 4:00 p.m., his blood pressure is 152 over 86, and his heart rate is now 115. The pain continues to be attributed to constipation, and the plan is to reexamine Louis after he gets up and walks around. We thought it was crazy, but we didn't know how to get out. We didn't know how to get help. We didn't know how to get in touch with anyone. I had no idea who, if anyone, the nurse answered to. I had no idea how to go above her head, which I certainly would have done. All I knew to do was to ask for a higher level physician, which I did persistently. One thing that it's good for the public to know is that in

health care. There's what I call different tribes. There's the doctor tribe, there's the nurse tribe, and other health care professionals who have their own tribe, whether it's pharmacists. And within each tribe, there's a pecking order, there's a hierarchy. So among physicians, there are medical students, then there are residents. Among residents, there's first-year residents who are still learning, very green. Then there's more seasoned residents who in their fourth year. Then there's senior attending physician. And a lot of miscommunication can happen up and down these hierarchies and across the different tribes. And it's important for patients and families to know who it is that they're talking to when they're in the hospital setting. And after a while, I realized there was some connection between my asking for the doctor and this exhausted looking little intern who would show up hours later. I made it very clear that I wanted an attending physician. I didn't know that term, but I asked for the doctors by name, and I said I want you.

know the two names that I knew. The doctor who had been on call on Saturday and Louis. I searched and I said I want one of them. Or I want to partner. And the nurse sort of rolled her eyes. She was very exasperated that we didn't think the intern was a doctor. I felt sorry for the intern. I wasn't trying to make life hard for her. She was out there standing by the computer. And I went up and tried to explain to her why I felt that I had to go over her head. And I listed all Lewis's symptoms again. And I said that it just doesn't seem right. It's concerning. I want. I want a Napper level doctor. Well, a lot of the bad things happened over a weekend, which is always a difficult time because even though there is cover, it's not necessarily fully staffed with attendings. They're mostly going to be working from home on-call. And although they're available and certainly can come in to deal with problems, they don't know there's a problem if they're not called.

and there's a strong culture in medicine that you don't ask for help if you don't. In fact, that people are to some extent looked down upon if they do ask for help. That's a perception. As Lewis was going downhill so rapidly, I was really alarmed. It was just me and Lewis there, and we were like an island. Nobody was paying any attention. People, they were taking vital signs and they were just going in the chart. I saw these huge black circles under his eyes, his cold sweat, this distended abdomen. It seemed quite alarming to me. No one was in charge. No one seemed to be pursuing goal-oriented behavior. They were just performing tasks. They were not trying to achieve an end. They were not trying to put it together. This was simply a system that was operating for its own benefit. The patients were really incidental. If you go into a hospital, there'll be many, many different people taking care of a patient. And the only folks who are the constant in that patient's life are the patient and the

they're the ones who see very nuanced changes in their loved ones' condition. They're the ones who are watching the different doctors and nurses come in at different shifts, evenings, weekends. They are that constant, so they have a crucial role to play in helping and partnering with healthcare professionals. Between 8 and 10 p.m. on Sunday night, a physician arrives to examine Luis, who Luis's mother believes is the on-call attending physician she has been requesting to see. He performs a physical exam and documents Luis's vital signs as stable, with a heart rate in the 80s. At the same time, contradictory to the doctor's note, a nurse documents in Luis's chart a blood pressure of 131 over 94 and a heart rate of 126. Luis's abdomen is noted to be distended, diffusely tender, and hard. He is also noted to be pale and diaphoretic. The physician lets the family know that Luis has a probable ileus secondary to the narcotics he is being given for pain.

management. The physician documents this clinical assumption in Louis's chart. Luis was making a reasonably normal recovery from surgery, and then there are a number of things that started to pop up that were clearly signs of a problem developing. For example, he had an increase in his heart rate, he had abdominal pain and distension, which he didn't have postoperatively. These individual pieces, rather than being put together in a coherent puzzle that said what the real problem was, were either ignored or individually discounted. Approach or closure as a not uncommon problem happens when somebody takes a series of facts, data, info, and rather than thinking it through carefully, tends to jump very quickly to a conclusion. For example, in Lewis's case, I think that the probable mental model was nothing much wrong except some constipation. So he had a little bit of abdominal distension, some abdominal pain that certainly would fit with constipation, but it completely ignores these other very serious abnormalities in heart rate and eventually blood pressure that suggested impending shock and circulatory collapse. And those were

pretty much completely ignored. It became clear after about two and a half days following the surgical procedure, the things weren't going away. They should have gone by that time. He should have been up and about in his room. His diet should have been advanced. His pain should have been well under control. But that's not what we saw lose his case. In his case, instead of the pain getting less, it got worse. And it got a lot worse. His heart rate had doubled. The pain had moved from his chest to his belly. And his belly was very tense. When the doctors who examined him came to see him and they put their hands on his belly, and all those things had made significant changes after he'd had the surgical procedure done. What they missed was an opportunity to ask the most important question that should always be asked in these circumstances: What's the worst it could be? And nobody asked that question. They all assumed in what is known as premature closure that this adolescent boy on the ward was suffering from either constipation or abdominal

gastrointestinal gas, and they all put it to that sort of early closure diagnosis, instead of asking what's the worst it can be. Diagnostic errors defined as missed, incorrect, or delayed diagnosis are a leading contributor to patient harm. An estimated forty to eighty thousand U.S. hospital deaths result from this diagnosis annually. The frequency of diagnostic errors may approximate 15%. Premature closure, the failure to consider reasonable alternatives after initial diagnosis has been reached, results in the correct diagnosis never being given serious consideration. Confirmation biases compel caregivers to seek information which confirms their original diagnosis while ignoring data that conflicts with. Confirmation biases lead to premature closure. Clearly, there was premature closure brought to their clinical diagnosis. Care providers made the diagnosis constipation gasps, yet there were many changing signs and symptoms that indicated otherwise. And as providers, we tend to do that at times, and we look at data that we want to reassure us of our clinical diagnosis while ignoring other data that conflicts with the diagnosis that we've come up with. And in turn, we tend to put blinders.

on and we lose that scope and in this case and Louis's care. I think that was clearly evident as story unfolds physicians do not always appreciate the possibility their diagnosis may be wrong. They may remain confident in their diagnosis despite conflicting signs and symptoms harm that comes from diagnostic error arises in cases when providers were certain of their diagnosis. So the doctor came in confirmed that it was Justin Elias just gas pains and that we would just have to ride it out. He was very confident, very reassuring so we thought we had gone as high up the food chain as we could go. We just hunkered down and hoped that by morning somebody who knew what they were doing who could help us would come when because when we certainly had realized that there were not many people around on Sunday at 12 midnight loses pulse oximeter alarms because the oxygen saturation in his blood has dropped into the mid 80s is put on oxygen. Luis continues to report severe abdominal pain his blood pressure is 137 over 85 and his heart

rate has climbed to 132 at 4:00 a.m. Louis's blood pressure is 140 over 100. His heart rate is about 140, and his respiration rate has climbed to 28 breaths per minute. He remains pale, nauseous, and weak. No changes are made to his assessment, and the plan is to see him again in the morning. Row mindfulness is an almost an ability to go back and second-guess your previous decisions and to say what's missing, what have I left out, what doesn't fit with the plan that we've got going on. Some people do it fairly naturally, and other people have to work it a little bit. But one of the ways that you can certainly make it happen is to deliberately ask yourself some simple questions. Things like, is everything explicable based on what I already thought, or do I need to change some of my thinking? Am I missing something here? Unfortunately, again, this is not something that most people really want to do because it makes it sound as though you're pretty indecisive if you

start doing this if you start second-guessing yourself in public. And the other thing is that if you do second-guess yourself and decide that you were wrong, you probably going to have to change the plan. And there's some momentum for any plan that's difficult to change once it started. So these are inconveniences that make it difficult for people to be mindful even when they might naturally have that inclination. But mindfulness is essentially going back and saying, Did I get this right? Is there something else I could be doing differently or better? And again, in this case, I would have hoped the mindfulness would have played a much greater role than it did. Oftentimes, physicians are uncomfortable admitting or disclosing uncertainty to patients and families. Additionally, many physicians do not tolerate uncertainty well, nor do many patients. Confidence is valued over uncertainty. It is considered a sign of weakness for caregivers to appear unsure. By warning the residents and medical students, the team came around and rounded, and Lewis's pain had suddenly disappeared. Just suddenly went.

away as quickly as it had come, and I knew again that couldn't be right. And just Plato says he still had no bowel sounds. He still had not urinated. He had no function. And then his pain disappears. And this so he was sort of frantic - and he said that to this team of young people that came in. II he said my pain has stopped. And that junior resident said oh good. So they recorded. They reported not in his chart but somewhere that that Luis was doing better because his pain had gone away. There were people who understood perfectly well that Lewis's condition was serious. And they never let on to us. They would come in. They would examine him in front of us. And act as though nothing was wrong. Did the night nurse I could. I when we got the chart later. I could tell that the night nurse was concerned. She never bled on to us. If she had, we would have done something. At 8:30 a.m. the vital signs technician records that Lewis has no blood pressure for over two hours.

nurses and the intern searched the hospital for a blood pressure cuff that works. They take Lewis's blood pressure 12 different times with seven different blood pressure cuffs without success. Instead of considering that a concerning symptom, they again concluded that it was the equipment. I started to scour the husband. The blood pressure machine was invite pressure cuffs at 9:30 a.m. The resident reports to the on-call attending surgeon and the surgical team or now in the operating room that Lewis does not have a blood pressure. The attending surgeon's concern is diffused by the fact that the junior resident has already reported the team at bomb Lewis better on morning rounds. His pain having subsided. At 10:45 a.m., the resident arrives from the operating room, takes Lewis's blood pressure, and records a blood pressure of 110 over 58. Shortly after, Lewis has an electrocardiogram. The documents are heartbreak the 163 beats per minute. At 12 p.m., Lewis is given a mother for the secretary-level.

phlebotomist arrived to take blood, but they struggle to find a vein. They proceeded to try to get some blood out of his arm, and there's almost no blood left, so they're squeezing and wringing his arm trying to get the blood out. And I get maybe half a tube. And Lewis starts to say something. I couldn't really understand him, and I leaned over, and he's saying very carefully, almost politely, saying, and there's words were sorority saying it's going black. And I just stared at him in her, and several seconds later he says again, I said it's going black. And then he just arced into cardiac arrest. His arms and legs were all about angles, his eyes were staring, his neck was back. Ah, I had no idea what it was, and I went running out of the room, and I found the chief resident walking casually down the hall, and I went running up to him, and I said he's seizing, he's seizing, and we ran together back into the room, and he called out.

very loud lays of Luis Luis at 12:05 p.m. Luis becomes inaudible. His family is asked to leave the room. Luis goes into full cardiac arrest. Chest tubes are put in. Brother resident who believes Luis has a pneumothorax. The code is called. Hopefully BAM for an hour. A team of surgeons, nurses, and residents tried to revive Lois but they are on people to do so. Lois's time of death is recorded as 1:21 p.m. Monday, November 6. We were standing there not knowing anything, knowing what to think. And then I turn around and there's this man at my elbow and he tells me he's the pastor. And then I realized that something very serious was happening and he saw it in my face and he said no, don't worry. I come to all the times. Then they came to get us and said the doctors wanted to talk to you. And we came out and we were walking down the hall, you know, just shaking. I thought, oh, now.

he he's he's brain damaged, so we went into this room, and there were five surgeons there, five attending physicians in green scrubs, and they said one of them introduced himself as that the doctor on call. We'd never met this doctor, we'd never even heard of him, and and he said we lost him. That made no sense to me, it didn't fit into anything anything that we had understood. I mean five minutes before this happened, they were still telling us he was fine, and now they act as though they've been fighting a valiant battle with a long illness and they lost that. And then they told us that they had no idea why Louis had died, that their chief resident had seen him the night before and hadn't found anything wrong, and that was the first we knew that the doctor the night before had not been the attending that we had requested. When we got home, we were expecting from, we thought that this was an earth-shaking event, and at the hospital would be in consternation, and that they

would be conducting investigations immediately, and that they would call us up, and you know, interview us, want to know what had gone wrong. They had to interview us. We were the only people who were there, but only surviving people who were there. All the time, I was the only person who knew everything that had happened to Luis. There was no way they could put together an investigation without my input and come to correct answers, which is exactly what happened. When we went down to see the surgeon, they constructed a theory that was completely wrong. A few weeks later, they sent us some literature in the mail on how to cope with grieving, but that was it, and we never heard from the surgeon about the autopsy. I think one of the most important points that we could take around these types of cases is while they're very unfortunate, we need to learn from them. It's also very important that we do the correct thing after the fact. What do we do defines who we are as providers and professional caregivers. Really helps promote healing. It helps bring closure.

and it's an important part of healthcare that's been lacking for many years. For generations in health care, there's been a sort of duck-and-cover. There's been this wall of silence that's been put up where patients and families were never told what happened and why. And the good news is, in recent years, more and more patients or families are saying that we want to be told the truth. We don't want to be abandoned. And the other good news is that there's more and more cases of physicians, nurses, and hospital executives, and others, and even lawyers and risk managers who are realizing that yes, we haven't done it right in the past, that we need to tell the truth to patients and families when there is a bad outcome. And the aftermath of adverse outcomes, we need compassion, empathy, and do the right thing. We'll just tell the truth to be with them throughout if they need follow-up medical care, provide that medical care, don't charge the patient and family, and to see them through it. It's much much

easier for patients and families when they are told the truth. The worst thing that we've done in health care over the years is to be honest. We've been lying to patients, we've been not telling them the truth, and that creates such a burden for them, particularly in cases such as Louis's. Family members do feel as if they are part of the problem, that it was their fault. That's a terrible burden that we put on them that should never be. The data is now showing that in the immediate aftermath of an adverse event, of a catastrophe, of a necessary harm, that you can maintain trust between patients and families and care providers if you provide ongoing, honest, and effective communication with those patients and families, and that communication continues on until there's a resolution and an understanding of the what and the why that occurred in these catastrophic events. And if you do that, it does support the healing that needs to go on within the hearts and the souls of the patients and families, as well as within the care providers and within the

institution and within the community as a whole. The first thing that should occur is for the institution to make a commitment to the family of the patient who's passed away that they will investigate what it is that's going on, and they will maintain very close communication with the patient's family as they begin to understand what it is it occurred. There are a lot of people who are harmed by this, certainly the patient's family is, but also the care providers who have been involved in the care of this child who's now died under their care, under their watch. And we can help the family heal and help the care providers heal, and often the best way to do that is to get all those parties together so they can maintain any trust that they did have, give that opportunity for everybody to learn from each other. This is on us what happened to Luis, we need to own that. Patients and families, we can tell them all these things that they should do, but ultimately it's our responsibility. The notion around just culture, the notion around reasons unsafe

acts algorithm is to look at the behavior the care providers, and to make certain that those that are involved in system errors are treated appropriately. They are treated in a way where we understand that they were in a system that was wired for things to go badly. On the other hand, if a doctor, or a nurse, or a pharmacist, or somebody else has been deemed to have behaved in a reckless manner, in a manner that exposed a patient to unnecessary risk knowingly, unexposed that patient to unnecessary risk, it's very important that institutions have a process in place to hold them accountable. Louis's autopsy report reveals his abdomen contained 2,000 cc's of bloody fluid, at 800 cc's of chocolate-brown blood clot. There is a circumferential ulceration of the duodenum mucosa, with an area of ulceration extending distally from this area for approximately two centimeters. Within the main area of ulceration is an area of perforation on the posterior wall. There appears to

erode into the anterior branch of the gastroduodenal artery four years before Louis's death. An article appeared in the Journal of the American Medical Association discussing the association between the use of ketorolac for post-operative pain management and subsequent gastrointestinal bleeding and death. Prior to that article, numerous case reports detailing the association between ketorolac and GI bleeding head wounds have been published. In this case, the caregivers caring for Lois did not seem mindful of this association. The relationship between ketorolac and GI bleeding is now prominently displayed in an FDA-mandated blackbox warning on the drug's package insert. And finally, a month later, we recall down there you really didn't understand, you know, the sequence of things, what had happened. So we, we told him what's happened, and he appeared to be shocked and disturbed, and he said, Do you blame yourself? And we said, Oh, every day, every minute, yeah, you feel guilty for every breath you take if your child that's dead. And he said, Don't blame yourselves. This is our fault.

this is our responsibility now, and at one point he started to cry, which to us made us feel better that he cared. It was a great relief to us. You it was very was open with us. He helped us get a copy of the medical records. They they were helpful to us. We met several times with pediatric surgeons. They answer to our questions to the best of their ability. If we don't talk about our mistakes, we're doomed to repeat them over and over and over again. So we have to have transparency and admit that we made a mistake in order to know what to do to try and prevent that mistake from happening again. And if we don't do that, shame upon us. Lewis was a boy of great promise. I don't think anything that I can do in his name will ever approach what he could have done for himself, but we have tried to create a legacy for him. So the Lewis Blackman Act would pass the South Carolina legislature in 2005. It it requires that that all hospital staff be

identified as to not only name and title department and and job status if they're whether or not they're a student or resident. And it requires that there'd be some kind of an emergency call system for patients. What would now be sort of a rapid response team, the patient-activated rapid response team. Never forget the time we interviewed a woman whose mother died, similar to what happened to Lois. It's called failure to rescue, and she said to this day, I regret not calling 911 alone. If Lois had been anywhere but in the hospital, he would be alive too. He died because he was in the hospital. It was the one place we did not get him the medical attention. The personal experience of others and forever changes all as long as patients are harmed by our care. We need to do everything possible to reduce risk and improve quality by openly discussing and analyzing errors when they occur. We can learn to improve the systems we work in by creating a culture of caring and compassion for patients and their families and for caregivers. We can also

learn better ways to help our patients. After harm does occur, we would like to thank Helen House Corner Family for sharing their story with us. Their ability to see beyond their loss and give back to the healthcare community will help us fix our systems and prevent similar harm from occurring to others. And finally, we would like to thank all of you for allowing us to share Lewis Blackman's story, for wanting to learn more about patient safety, and for caring enough to make a difference.

Transparent Health - Lewis Blackman Story

SolidLine Media is a Chicago based high end video production company that specializes in commercial, educational, documentary, and promotional video.

Call SolidLine at (312) 648-6600 to learn more about our services!

solidlinemedia

의료 오류가 환자와 간병인에게 미치는 영향

의사와 간호사는 환자를 돌보면서도 실수를 저지르고 환자와 그 가족에게 영향을 미칩니다.

의료사고에 대한 의료진의 대응은 치료 과정과 환자와의 신뢰 회복에 매우 중요합니다.

이 교육용 동영상 시리즈는 실제 임상 사례를 통해 의료 오류 예방과 환자 스스로의 적극적인 치료 역할 등 의료 분야의 중요한 문제를 다루고 개선을 위한 학습 기회를 제공하는 것을 목표로 합니다.

조기 폐쇄가 환자 치료에 미치는 영향

조기 폐쇄는 진단 오류와 환자 피해로 이어질 수 있으므로 불확실한 경우 도움을 요청하도록 장려하는 안전 문화의 중요성이 강조됩니다.

간호사와 의사가 도움을 요청할 수 있도록 권한을 부여하면 환자 피해를 크게 줄일 수 있습니다.

신속한 대응 프로세스와 간병인, 환자 및 가족과의 투명한 의사소통은 피해 발생 시 신뢰를 유지하고 기대치를 충족하는 데 매우 중요합니다.

주말에 인력이 충분하지 않으면 환자 치료에서 합병증과 오류가 발생할 수 있습니다.

의료 전문가 간의 명확한 위계질서와 의사소통이 부족하면 관리가 잘못되고 필요한 치료를 받는 데 지연이 발생할 수 있습니다.

환자와 그 가족은 주말 입원 기간 동안 의료 시스템을 탐색하고 숙련된 의사의 개입을 옹호하는 데 어려움을 겪을 수 있습니다.

적절한 의료 서비스를 위한 옹호

한 어머니가 의료진이 아들의 상태가 악화되는 것을 심각하게 받아들이지 않는다고 생각하여 아들의 적절한 치료를 요구합니다.

의료진이 효과적인 의사소통과 조율에 실패하여 오진이 발생하고 심각한 증상을 간과하게 됩니다.

이 사례는 더 나은 결과를 위해 의료 전문가와 협력하는 데 있어 환자와 그 가족이 중요한 역할을 하는 것이 얼마나 중요한지 강조합니다.

진단 오류가 환자 치료에 미치는 영향

진단 누락, 부정확한 진단, 진단 지연 등 진단 오류는 미국에서 연간 병원 사망의 상당수를 차지하는 원인입니다.

확증 편향으로 인한 임상 진단의 조기 종결은 종종 환자에게 심각한 해를 끼칩니다.

불확실성에 대한 의사의 불편함과 환자와 가족에게 이를 공개하는 것을 꺼리는 것도 진단 오류와 환자 피해의 원인이 될 수 있습니다.

의료 과실과 잘못된 관리: 비극적인 이야기

병원 직원은 가족의 우려에도 불구하고 루이스를 제대로 모니터링하고 진단하지 못해 치명적인 결과를 초래합니다.

의료진의 소통 부족과 가족을 조사에 참여시키지 않은 것은 상황의 트라우마를 더욱 가중시켰습니다.

이러한 사건 이후 적절한 절차에 대한 가족의 요구는 학습, 시정 조치, 애도 지원의 필요성을 강조합니다.

의료 서비스에서 진실과 소통의 중요성

의료계에서는 특히 부작용이 발생한 후 환자와 그 가족에게 정직과 배려의 필요성에 대한 인식이 높아지고 있습니다.

좋지 않은 결과가 발생한 후에도 환자 및 가족들과 솔직하고 개방적인 의사소통을 유지하는 것은 신뢰를 구축하고 유지하는 데 매우 중요합니다.

의료기관은 책임을 지고, 사건을 조사하고, 영향을 받은 가족과 의료진이 모두 치유할 수 있도록 지속적인 지원과 소통을 제공해야 합니다.

케토롤락이 환자 안전에 미치는 영향

케토롤락 사용은 위장관 출혈 및 사망과 관련이 있어 FDA에서 블랙박스 경고를 의무화했습니다.

루이스 블랙맨의 비극적인 죽음은 병원 안전 조치를 개선하기 위한 루이스 블랙맨 법안을 촉발시켰습니다.

블랙맨 가족의 옹호는 환자 치료의 투명성, 오류 분석 및 배려의 문화를 강화하는 데 영감을 주었습니다.