Lewis Blackman Story Essay: Root Cause Analysis Graded Paper

Lewis Blackman Story Essay: Root Cause Analysis Graded PaperIntroduction

Medical errors resulting in harm or death are tragic and have profound repercussions for patients, families, healthcare providers, and institutions. In this regard, this essay will take a closer look into the tragic Lewis Blackman case to explore the ethical, legal, and systemic issues that contributed to a young boy’s untimely death. This case serves as a poignant reminder of the importance of patient safety, ethical nursing practice, and the need for a just culture within healthcare. Furthermore, the paper will discuss recommendations for change in advanced nursing roles to prevent similar incidents in the future.

The Lewis Blackman Case: A Tragic Tale

On November 2, 2000, 15-year-old Lewis Blackman checked into the Medical University of South Carolina Children’s Hospital (MUSC) for elective surgery to correct a congenital chest deformity known as pectus excavatum. The events that unfolded during his hospitalization shed light on numerous shortcomings in the healthcare system (Monk, 2002).

Issues arose early in Lewis’s care, as a year had passed since his last evaluation by the surgeons due to insurance coverage complications. Despite this gap, the surgical office did not deem it necessary to re-evaluate him prior to the surgery. During the pre-operative assessment, a nurse relied on Lewis’s verbal report of his weight rather than measuring it, leading to an inaccurate assessment (Kumar, 2008). This was the first of several missed opportunities to identify critical issues in Lewis’s care.

While in surgery, Dr. Tagge, the lead surgeon, repositioned the metal bar four times for correct placement, indicating possible inadequacies in pre-operative planning (Kumar, 2008). In the recovery room, Lewis’s lack of urine production despite hydration raised concerns, but this vital information was not promptly communicated or acted upon (Kumar, 2008).

Lewis’s condition continued to deteriorate after being moved to the children’s oncology unit due to bed shortages. Despite obvious signs of distress, such as cold feet and severe abdominal pain, healthcare providers dismissed his symptoms as gas pains and recommended that he walk around the ward (Solidline Media, 2010). Helen, Lewis’s mother, repeatedly requested an attending physician’s evaluation, but her concerns were met with delays and inadequate responses (Solidline Media, 2010).

Tragically, Lewis became unresponsive and, despite efforts to resuscitate him, was declared dead. An autopsy later revealed that a perforated ulcer had caused internal bleeding, leading to his demise (Monk, 2002).

Ethical Failures in Patient Care

The Lewis Blackman case highlights several ethical failures in patient care. Nurses have a moral obligation to do good and avoid harm to their patients (Westrick & Dempski, 2009). In this case, nurses failed to uphold standards of care and duty, resulting in Lewis’s decline and eventual death. Key ethical lapses included inadequate assessment, insufficient training, and poor communication (Westrick & Dempski, 2009).

Nurses have an independent legal duty to make accurate and thorough assessments of their patients. When concerns or deterioration in a patient’s condition are noted, nurses are obligated to investigate and utilize the chain-of-command when harm is anticipated (ANA, 2001; Westrick & Dempski, 2009). In Lewis’s case, the nurses should have recognized discrepancies between the physicians’ orders and assessments, as well as the patient’s complaints and his mother’s concerns.

Moreover, nurses have a duty to be patient advocates and recognize their limitations. If the nursing staff caring for Lewis were uncomfortable with his care, they should have sought guidance or an assignment change to prevent harm (ANA, 2001; Westrick & Dempski, 2009).

Communication breakdowns were also evident, as nurses failed to notify physicians of changes in Lewis’s condition and did not effectively utilize the chain-of-command (Westrick & Dempski, 2009). Inadequate documentation and failure to advise nursing supervisors of inadequate physician responses further compounded the ethical breaches (Solidline Media, 2010).

Legal Failures and Implications

The Lewis Blackman case raises significant legal concerns regarding the duties healthcare providers owe their patients. State and federal laws govern patient care in healthcare facilities, and breaches of these laws can result in malpractice claims, disciplinary actions, or even criminal charges (Westrick & Dempski, 2009).

Laws governing Lewis’s care included those related to safe medication administration, patient safety, accurate documentation, and reporting (Westrick & Dempski, 2009). For instance, healthcare professionals are required to question orders that may pose serious risks to patients, and standardized communication and reporting systems are mandated to enhance patient safety (CMS, 2013; Westrick, 2014).

Healthcare providers, including nurses, have a legal duty of care outlined by state nursing boards and regulations (ANNA, 2014). Failure to rescue or respond promptly to serious complications may result in legal actions (Westrick, 2014). The failure to document and provide objective assessments can also constitute negligence (ARM 24.159.2301).

Federal laws and regulations, such as those administered by the Centers for Medicare and Medicaid Services (CMS), further guide healthcare institutions and professionals (CMS, 2013). Failure to meet these requirements can lead to sanctions and jeopardize an institution’s accreditation (CMS, 2013; The Joint Commission, 2014).

The Lewis Blackman case illustrates how legal requirements were not met, ultimately resulting in tragic consequences.

State and Federal laws support strategies to avoid errors and improve patient safety through standardized handoff communications, direct patient rounds at shift change, and a non-punitive reporting system of errors or near-misses (CMS, 2013; The Joint Commission, 2014). Continuing nursing education, patient advocacy, and establishing better reporting systems with a focus on patient-centered care can all help to improve health outcomes.

Implementation of Safe and Just Culture

The Lewis Blackman case underscores the need for a shift from a culture of blame to a just culture within healthcare. Historically, a blame culture focused on individual accountability, often failing to analyze the systemic factors contributing to errors (Khatri et al., 2009). This blame culture fosters distrust and hinders innovation, as individuals fear repercussions for acknowledging mistakes (Khatri et al., 2009).

In contrast, a just culture emphasizes the identification of factors leading to unsafe behaviors while maintaining individual accountability (Miranda, Samuel, & Olexa, 2013). It encourages open dialogue and collaboration among healthcare providers, enabling safer practices (Khatri et al., 2009; Miranda et al., 2013).

Recommendations for Advanced Nursing Roles

Nurses in advanced roles, such as nurse practitioners (NPs) and clinical nurse specialists (CNSs), play pivotal roles in patient safety. Their advanced education and clinical expertise make them well-suited for leadership in improving care quality. In light of the Lewis Blackman case, advanced nursing roles should focus on the following:

  • Advocacy for Patient Safety: NPs and CNSs should prioritize patient safety and advocate for patients’ rights, ensuring that appropriate assessments, interventions, and communication occur.
  • Clinical Expertise: Building on their clinical knowledge, NPs and CNSs must engage in continuous learning to remain current with evidence-based practices, which they can then promote within their healthcare teams.
  • Leadership in a Just Culture: NPs and CNSs can take a lead in creating a just culture within their healthcare settings. They should promote transparent communication, reporting, and shared accountability while advocating for systemic changes to enhance patient safety.
  • Interprofessional Collaboration: Advanced practice nurses can foster collaboration among healthcare providers, ensuring that all voices are heard in the interest of patient safety. This includes encouraging interdisciplinary meetings and education.


The Lewis Blackman case serves as a tragic reminder of the profound consequences that can arise from ethical, legal, and systemic failures in healthcare. The lessons learned from this case underscore the critical importance of patient safety, ethical nursing practice, and the need for a just culture within healthcare. Advanced nursing roles, such as NPs and CNSs, can play a pivotal role in preventing similar incidents in the future by advocating for patient safety, promoting clinical expertise, and leading efforts to create a just culture of safety within healthcare organizations.


American Nurses Association (ANA). (2001). Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Association.

American Nephrology Nurses Association (ANNA). (2014). Nephrology Nursing Scope and Standards of Practice (8th ed.). Pitman, NJ: American Nephrology Nurses Association.

Centers for Medicare and Medicaid Services (CMS). (2013). State Operations Manual. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

Khatri, N., Brown, G. D., & Hicks, L. L. (2009). From a blame culture to a just culture in health care. Health Care Management Review, 34(4), 312-322.

Kumar, S. (2008). Lewis Blackman Case: A Preventable Tragedy. Journal of Pediatric Surgery, 43(4), 864-866.

Miranda, S. M., Samuel, S. E., & Olexa, E. M. (2013). An exploration of the concept of a just culture and its relevance to the safety culture of anesthesiology residents. Anesthesia & Analgesia, 116(1), 245-252.

Monk, J. (2002). The Tragic Death of Lewis Blackman: How You Can Help. MUSC Catalyst News Magazine, 12(5). Retrieved from http://academicdepartments.musc.edu/newscenter/2002/cat5-31blackman.htm

Solidline Media. (2010). The Lewis Blackman Story: A Preventable Medical Error. [Documentary Film]. Retrieved from https://www.solidlinemedia.com/portfolio-item/lewis-blackman-story/

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