Lewis Blackman Hospital
Patient Safety Act
SC Code Ann.
§44-7-3410 et seq.
Annette Drachman, JD, MHA
Director, MUHA Legal Affairs
Rosemary Ellis, MSN
Director, Quality and Patient Safety
Background
15 year old , Lewis W. Blackman was
hospitalized at Children’s Hospital at MUSC
in late October 2000 for elective surgery.
Over the weekend, his mother reported
Lewis having some post-op complaints.
Lewis was seen by the upper level Resident,
who communicated the symptoms to the Attending.
What happened next?
On Monday, November 2, the new
Attending received a verbal report from
the Resident that the patient was stable.
The Attending then went to the OR.
Lewis died later that day from internal
bleeding
“For more than a year [Helen Haskill]’s been fighting
to get a modest bill enacted in South Carolina that
would require hospitals to display the ranks of
medical personnel on name badges, to explain their
roles in a patient’s care and to give families an
emergency number to call if they believe their
patient is not getting proper medical attention.”
Fatal Mistakes
By Trudy Lieberman
November 2004
Lewis was Helen Haskill’s son
Lewis Blackman Hospital Patient
Safety Act
Three Primary Areas in the Act
Name Badges
Informing Patients who is involved in their care
Establish a mechanism to contact the Attending
Physician
Name Badges
Identify all clinical staff (includes “persons who
work in a hospital whose duties include personal
care or Medical treatment of patients”):
All Identification Badges for direct
clinical care staff are being replaced.
Must include
Name (first and last)
Department
Job or trainee title
Must be
Clearly visible
In terms or abbreviations reasonably
understood
Informing Patients
(Written Information)
This act requires specific information be provided to all
inpatient and ambulatory surgery patients at the time of
admission or as soon as possible thereafter.
Information includes identification of who is involved
in their care and the mechanism to contact the attending.
We have designed a brochure that includes all the
information required by the act.
Patient registration staff are required to give the
brochure to the patient.
We are revising the general consent for treatment to
include documentation of the patient’s receipt of the
brochure.
Check to make sure your patient has
received this brochure.
Mechanism to contacting the
Attending Physician
Whenever the patient or family member asks to speak to the attending
physician about their medical care:
Determine what concerns the patient or family have to determine if you
can take care of it immediately.
If you are not able to respond to the concern - page the attending
physician by calling 2-8080.
Rationale: Monitoring the documentation
If the patient or family member would like to page the attending
themselves, give them this number 792-8080.
Document all patient/family member requests to and your actions in the
interdisciplinary progress notes of the medical record.
Never give out personal pager numbers.
HOW DO I COMPLY?
Follow MUSC requirements by:
Completing ALL information on white
board at the BEGINNING of the shift, if
utilized in your area.
Wear your name badge in a visible
location (eye level is recommended)
HOW DO I COMPLY?
If unable to respond to requests appropriately, contact the
Attending MD (or attending designee) at patient
(or patient representative) request regarding
medical concerns.
If you page the attending physician at the request of the
patient, you must document that in the progress note in
the medical record (see pocket card).
Ensure that patient/family has copy of MUSC
pamphlet “An Academic Medical Center of Excellence”
WHAT IF I CAN’T REMEMBER
WHAT I AM SUPPOSED TO DO?
Check the poster supplied to your unit.
Keep your pocket card handy
STATE Enforcement
Enforced by DHEC against the
HOSPITAL’s license
DHEC will investigate complaints and
issue citations
Added to routine inspections
Policy changes
The following policies have been revised
to reflect the requirement:
C-124 Paging Responsibilities and
Response Time
C-109 Chain of Command Policy
A-7 Identification Cards
C-74 Resident Supervision
The following slides contain helpful
information that is not a part of the act.
Medical University of South Carolina
Administrative Chain of Command
Any Staff
Member
Supervisor for your area
(Charge Nurse on duty if
applicable)
Area Manager
(After-hours-inpatient- Hospital
Services Coordinator)
Director of indicated area
Administrator
of the area
Activate the chain of command when you believe the patient to be at risk
and there is a delay in medical response
Stat page the MD and request
a bedside assessment when:
► You are concerned/worried about the patient
► Acute change in any of the following:
heart rate 130 bpm
systolic blood pressure 24 per min.
blood oxygen saturation less then 90% despite O2
mental status (delirium, confusion, agitation)
urinary output <50 ml in 4 hours
Fractional inspired oxygen (FiO2) of 50% or greater
► New, repeated, or prolonged seizures
► Failure to respond to treatment for an acute problem/symptom
► Blood Glucose <70 mg/dL (after initiating hypoglycemia protocol)
Paging a Physician
Request 2-8080 2-0590/Online
Patient or Patient √
Representative Attending
requests
Urgent patient care Preface the # with “STAT”
issue (STAT-2-2623)
5 min response time is
expected
Non-urgent patient Text page with the information
care issues or request
Remember
A Resident MD is not an
Attending physician.