title: Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.
abstract: Lewis Blackman was a 15-year-old boy who died 4 days after having surgery to correct a congenital deformity of the chest. The story of his death serves as a chilling reminder that quality and safety are not abstract ideals but rather tangible goals designed to prevent tragedies like the one experienced by Lewis Blackman's family. The authors sought to find an explanatory model for the events that transpired and posit that the answer lies at the intersection of several distinct yet interrelated phenomena: (a) the failure of dual process theory; (b) anchoring and belief perseverance; (c) the role of power and authority; and (d) the fragmented care delivery system in the hospital setting. To prevent similar tragedies in the future, the authors propose 5 strategies for nursing educators: incorporate "cognitive unmooring" questions into student assessments of patients; integrate information about System 1 and System 2 thinking into the didactic portion of the curriculum; include cases similar to Lewis Blackman's into simulation experiences; ensure that students learn how to recognize and address authority gradients with supervisors, physicians, and other members of the health care team; and provide students with experiences including the patient/family as members of the care team.
authors.affiliation: George Washington University, School of Nursing, Washington, DC 20036, USA. acqua@gwu.edu
authors.forename: Kimberly
authors.initials: K
authors.lastname: Acquaviva
authors.forename: Helen
authors.initials: H
authors.lastname: Haskell
authors.forename: Jean
authors.initials: J
authors.lastname: Johnson
mesh_terms: D000293:Adolescent; D003071:Cognition; D000013:Congenital Abnormalities / Q000601:surgery*; D003657:Decision Making; D006801:Humans; D008297:Male; D019300:Medical Errors; D011787:Quality of Health Care