Root Cause Analysis: Lewis Blackman Case Essay

Table of Contents
  1. Abstract
  2. Introduction
  3. Root-Cause-Analysis
  4. Why Does This Exist?
  5. Rationale
  6. Conclusion
  7. References

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The sentinel occasion that’s the foundation of this RCA paper is the Lewis Blackman case. Lewis had pectus excavatum and was taken right into a educating hospital for an operation to repair his situation (“Patient story,” n.d.). Lewis skilled extreme ache after the operation and was placed on opioids and Toradol. On the third day, he skilled extreme ache in his abdomen space, which the nursing employees identified as ileus.

The affected person’s situation worsened, his blood strain dropped, and he turned pale. However, the medical personnel by no means contacted an attending doctor to evaluation Lewis’ case. On the fourth day after the surgical procedure, Lewis had a cardiac arrest and died. The post-mortem confirmed that he had a perforated duodenal ulcer, which is a complication from Toradol. The Lewis Blackman case is a situation the place lack of expertise and negligence from the medical personnel, which led to an inaccurate evaluation of significant indicators and a choice to change the heart beat oximeter settings resulted in an inaccurate evaluation and affected person’s loss of life.


The challenge that this RCA handle is the negligence from the medical personnel that led to them lacking indicators of perforated duodenal ulcer. Firstly, Lewis was in a educating hospital, which implies that almost all of physicians have been of their first years of coaching {and professional} work. They didn’t deal with Lewis’s case critically, since at first, his low oxygen saturation was attributed to bronchial asthma, and the heart beat oximeter was set to 85% and finally turned off (“Patient story,” n.d.). Moreover, the employees didn’t acknowledge that this affected person’s case is critical, and they didn’t contact an attending doctor to evaluation Lewis’s important indicators, even after they may not measure his blood strain. Finally, a perforated duodenal ulcer is a typical and lethal complication of Toradol, a ache remedy that Lewis was placed on.

However, the medical personnel didn’t verify if this affected person was affected. As a outcome, Blackman underwent septic shock and died. Hence, this paper will handle the negligence and failure to supply correct care by the employees of the educating hospital the place Lewis Blackman underwent surgical procedure, which led to his loss of life.


The methodology of study utilized on this paper to establish the underlying drawback that led to Lewis’ loss of life is the RCA. RCA is a “is the process of discovering the root causes of problems in order to identify appropriate solutions” (“Root cause analysis explained,” n.d., para. 12). Additionally, Figure 1 is a fishbone diagram that illustrates the situation and the various components that led to Lewis’s loss of life. Hence, by means of root trigger evaluation, the problems that led to Lewis’s loss of life will likely be recognized.

Figure 1. Fishbone diagram for Lewis Blackman’s case (created by the creator).

The challenge in query is the septic shock that led to Lewis’s loss of life on the fourth day after his minor surgical procedure. The components displayed in Figure 1 that led to this final result are not any supervision, lack of expertise of the physicians who monitored Lewis, protocols of this hospital, important indicators evaluation failures, communication issues, and gear. Hence, since this hospital allowed trainees to work freely on affected person instances and the latter didn’t query their capacity to diagnose instances correctly, they didn’t assess affected person’s vitals and even turned off the oxygen monitor and didn’t take note of the blood strain monitor’s outcomes. Moreover, the physicians didn’t talk with their skilled colleagues and ignored dad and mom’ considerations about urination lower.

Some phrases which can be necessary for this case are perforated duodenal ulcers, that are open sores that develop within the gut or abdomen. This ulcer led to the event of sepsis, and septic shock, which is a results of an an infection that results in a drastic blood strain drop. Toradol is a model identify of the ache remedy Ketorolac, which is an anti-inflammatory drug used to handle ache.

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When deciphering the knowledge from this case examine, it’s evident that there are a number of systemic errors that resulted within the failure to acknowledge the affected person’s septic shock and stop his loss of life. Firstly, the physicians made a number of assumptions about Lewis’s state that weren’t backed by satisfactory knowledge, important indicators evaluation, or an attending doctor. Second, the affected person was placed on IV ache killer remedy with out satisfactory fluids or a recognition of the potential negative effects from Toradol, which factors to an absence of protocols on this hospital that will require physicians to observe sufferers on this remedy extra intently. Finally, the miscommunication was a major problem as Lewis’s dad and mom voiced involved in regards to the decreased urination; the personnel didn’t take note of this symptom. Moreover, the medical employees and the dad and mom didn’t talk clearly over the course of this case.

Why Does This Exist?

The drawback of negligence is a results of two components, the primary one is improper supervision on the coaching hospital, and the second is the lack of the younger physicians to acknowledge their lack of expertise and experience. These two components led to the employees failing to acknowledge that Lewis’s signs weren’t per the usual postoperative negative effects and request an opinion of the attending physicians. This is a long-term drawback within the healthcare system since there’s a lack of medical professionals total, which is a possible cause why the inexperienced physicians weren’t supervised. Additionally, the systemic errors are a results of the insufficient protocols in a hospital that will require checking sufferers who bear even minor surgical procedures. Following the 5 why’s strategy, these conclusions might be made:

  1. The affected person died from septic shock.
  2. The improvement of sepsis was not acknowledged.
  3. Vital indicators, equivalent to oxygen saturation and blood strain, have been ignored.
  4. The personnel was inexperienced and didn’t request help.
  5. Hospital guidelines and protocols didn’t define the administration of sufferers on Toradol and allowed trainees to work with sophisticated sufferers unsupervised.


There are examples of affected person instances the place the latter developed duodenal ulcers and had extreme bleeding linked to the usage of Toradol. For instance, Pham et al. (2020) report a affected person case of an 80 years outdated man present process orthodontic surgical procedure who developed duodenal ulcers because of utilizing non-steroid ache remedy. The negative effects of Toradol are well-examined, and Hutka et al. (2021) report that “nonsteroidal anti-inflammatory drugs (NSAIDs) induce significant damage to the small intestine, which is accompanied by changes in intestinal bacteria (dysbiosis) and bile acids” (p. 664177).

Moreover, Russo et al. (2017) state that the extended use of Ketorolac is suggested in opposition to since it’s related to adversarial kidney and gastrointestinal occasions. Finally, it’s evident that on this case, the personnel failed to acknowledge the indicators of septic shock. According to Backer et al. (2021), these are decreased urination, blood strain points, and paleness. All of those indicators have been current on the third day after Lewis’s surgical procedure.


In abstract, this paper focuses on the problems of negligence and hospital insurance policies resulting in Lewis Blackman’s loss of life are mentioned. Some suggestions embody making certain that the hospital insurance policies spotlight the potential negative effects of Toradol. Additionally, the trainees should report any sudden or uncommon modifications within the affected person’s important indicators to attending physicians. Even minor surgical procedure affected person instances needs to be intently monitored and reviewed by supervisors.


De Backer, D., Ricottilli, F., & Ospina-Tascón, G. (2021). Septic shock: A microcirculation illness. Current Opinion in Anaesthesiology, 34(2), 85-91. Web.

Hutka, B., Lázár, B., Tóth, A., Ágg, B., László, S., & Makra, N. (2021). The nonsteroidal anti-inflammatory drug ketorolac alters the small intestinal microbiota and bile acids with out inducing intestinal harm or delaying peristalsis within the rat. Frontiers in Pharmacology, 12, 664177. Web.

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Patient story. (n.d.). Web.

Pham, M., Dunlop, N., Pham, L., & Turvey, T. (2020). Severe bleeding from a duodenal ulcer after orthognathic surgical procedure: A case report. International Journal of Oral and Maxillofacial Surgery, 49(6), 794-796. Web.

Root trigger evaluation defined: Definition, examples, and strategies. (n.d.). Web.

Russo, R., De Caro, C., Avallone, B., Magliocca, S., Nieddu, M., & Boatto, G. (2017). Ketogal: A spinoff Ketorolac molecule with minor ulcerogenic and renal toxicity. Frontiers in Pharmacology, 8, 20-30. Web.

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