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One of the key root causes identified in the "People" category was the failure of the staff to recognize and escalate early signs of opioid induced respiratory depression in an adolescent patient. Staff who care for pediatric patients receiving opioids should receive recurring, age-specific education on early signs of opioid induced respiratory depression. This should cover differences in pediatric pharmacology, appropriate use of sedation scales, and when to escalate concerns. Simulation-based training can improve recognition and response times in real-life scenarios, reducing harm and improving patient outcomes. This intervention directly addresses the root cause of underpreparedness among staff, as highlighted in the people category of our RCA. By increasing clinical competence and confidence, especially in high-risk populations, healthcare teams will be better equipped to prevent events like the one in this case.

BU

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Informed consent is one of the most important factors of healthcare. Every patient has the right to know exactly what will occur during a procedure and the risks that come along with it. Consent was a major missing material regarding the case of Lewis Blackman. In Blackman's case, a one paragraph paper with little detail was given to the Blackman's and no discussion was had regarding the details of the procedure. Evidence-based practice would include an intervention of providing a concise, comprehensive, and understandable document to be read by the consenting party along with a discussion on what they will be consenting to.

KD

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Grant, S. C. (2021, April 28). Informed Consent—We Can and Should Do Better. JAMA Network Open. https://doi.org/10.1001/jamanetworkopen.2021.2799253

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Acquaviva, K., Haskell, H., & Johnson, J. (2013). Human cognition and the dynamics of failure to rescue: The Lewis Blackman case. Journal of Professional Nursing, 29(2), 95–101.

https://www.clinicalkey.com/nursing/#!/content/journal/1-s2.0-S8755722312002979

Vecchione, T., & Monitto, C. L. (n.d.). Opioid-induced respiratory depression—Pediatric considerations. Anesthesia Patient Safety Foundation. https://www.apsf.org/article/opioid-induced-respiratory-depression-pediatric-considerations/

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One of the main issues with the setting of the hospital that was expressed by Lewis Blackman's mother was the lack of communication between his interdisciplinary team and the general dismissiveness of the environment. She felt that  asking for communication or help was an inconvenience and there was no proper communication between the staff members. In order to provide respectful patient and family-centered care in pediatric cases, communication skills need to be prioritized as well as clinical skills. Furthermore, she had explained that many of the nurses seemed unwilling to contact the providers and often would not respond to her calls. To combat these experiences Lewis Blackman’s mother had faced, hospitals can implement required communication programs to improve multidisciplinary and patient-provider conversations. This intervention would enhance staff confidence to speak up to their coworkers when concerned, feel more comfortable with speaking to patients’ parents, and overall increase the quality of care and patient safety.

AE

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Khoo, S. A., Aswin, W., Shen, G. Q. Y., Haq, M. M., Junaidah, B., Yiew, J. L., Abiramy, M., & Sashikumar, G. (2020, September). Improving provider‑patient communication skills among doctors and nurses in the children’s Emergency Department. The Asia Pacific Scholar, 5(3). https://doi.org/10.29060/taps.2020-5-3/oa2160

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To address the root cause of inadequate methods in the Lewis Blackman case, several evidence-based interventions can strengthen system safety. Using structured communication tools like SBAR can improve the clarity of handoffs and support timely escalation of patient concerns across care teams. Empowering families through rapid response systems such as Condition Help gives them a direct voice in care when deterioration is suspected but not acknowledged by staff. Ensuring the presence or immediate availability of attending physicians, particularly during weekends and post-operative periods, helps prevent critical delays in decision-making caused by inexperienced or unsupervised trainees. Incorporating pediatric-specific clinical decision support tools within the electronic health record reduces medication errors by alerting providers to age-based contraindications. Enhancing the informed consent process with visual aids and structured discussions also promotes better understanding, risk awareness, and shared decision-making with patients and families. These interventions work together to improve patient safety by addressing the procedural breakdowns that contributed to Lewis’s preventable death.

HT

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Hueckel, R., Boehm, B., & Goolsby, M. J. (2020). Implementation and outcomes of family-activated rapid response systems. Journal of Pediatric Nursing, 54, e42–e47. https://doi.org/10.1016/j.pedn.2020.04.003

Institute for Healthcare Improvement. (2020). SBAR Tool: Situation-Background-Assessment-Recommendation. https://www.ihi.org/resources/Pages/Tools/SBARTool.aspx

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One root cause related to equipment in the Lewis Blackman case was the lack of appropriate monitoring devices and safety alerts to detect early signs of deterioration. Evidence-based practice recommends implementing advanced monitoring technologies, such as continuous pulse oximetry and capnography, particularly for pediatric patients receiving opioids. These devices allow for early recognition of respiratory depression and prompt intervention. Additionally, integrating smart infusion pumps with dose-error reduction systems can help prevent medication overdoses. Regular staff training on equipment use and ensuring equipment is readily available and properly maintained can further enhance patient safety.

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Niesters, M., Mahajan, R. P., & Aarts, L. (2013). Assessment of respiratory depression by capnography in procedural sedation and analgesia: A clinical review. British Journal of Anaesthesia, 110(6), 877–884. https://doi.org/10.1093/bja/aet002

Weinger, M. B., & Lee, L. A. (2011). No patient shall be harmed by opioid-induced respiratory depression. Anesthesia Patient Safety Foundation Newsletter, 26(2).