The Lewis Blackman Hospital Patient Safety Act: It's Hard to Kill a Healthy 15- year Old
Julie K. Johnson, Helen Haskell and Paul Barach
1. Where did the system fail Lewis and his family?
2. What were the system failures in Lewis's case process related to :
a. Preparation?
b. Organization?
c. Environment?
d. Technology?
e. Work Tasks?
f. Healthcare providers?
3. Where in the process of care did incidents (errors, near misses. Adverse events, and harm) occur?