Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Kimberly Acquaviva; Helen Haskell; Jean Johnson

Commentary

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

September 12, 2016

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29(2):95-101.

View more articles from the same authors.

This commentary reviews the death of a patient to identify factors that contributed to the incident, including cognitive biases and poor communication between clinicians, and recommends strategies to address them.

PubMed citation

Available at

Related Resources From the Same Author(s)

Families as partners in hospital error and adverse event surveillance.

April 24, 2018

Human centered design workshops as a meta-solution to diagnostic disparities.

November 2, 2022

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.

October 4, 2023

In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.

September 6, 2023

Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.

August 9, 2023

Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023.

February 7, 2024

Family safety reporting in hospitalized children with medical complexity.

July 20, 2022

Family safety reporting in medically complex children: parent, staff, and leader perspectives.

July 6, 2022

Health care provider factors associated with patient-reported adverse events and harm.

May 20, 2020

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice.

November 15, 2017

Related Resources

Patient Safety Innovations

Rescue Improvement Conference Innovation Summary

July 23, 2024

Failure events in transition of care for surgical patients.

September 12, 2016

Improving heparin safety: a multidisciplinary invited conference.

May 11, 2014

The cost of disruptive and unprofessional behaviors in health care.

October 16, 2013

National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA.

July 17, 2013

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

January 18, 2013

Toward improving patient safety through voluntary peer-to-peer assessment.

May 24, 2012

Variations in surgical outcomes associated with hospital compliance with safety practices.

May 24, 2012

Validity of Patient Safety Indicators in the Veterans Health Administration.

June 22, 2011

Smart pumps: advanced capabilities and continuous quality improvement.

February 14, 2007

See More About The Topic

Hospitals

Health Care Providers

Health Care Executives and Administrators

Safety Scientists

General Internal Medicine

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Rescue Improvement Conference Innovation Summary

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Rescue Improvement Conference Innovation Summary

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site

Submit Your Training

Continue as a Guest

Continue Logged In

Submit Your Training

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your Toolkit

Continue as a Guest

Continue Logged In

Submit Your Toolkit

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your WebM&M Case

Continue as a Guest

Continue Logged In

Submit Your WebM&M Case

Continue as a Guest

Already have a PSNet

Account?

New Users