Root Cause Paper

Introduction with Problem Statement
In today’s complex and high pace health systems, the power of the individual is entirely ineffective compared to that of a highly efficient and collaborative team. However, these professional healthcare organization systems can be tarnished by the presence of “tribes” among nurses, physicians, students, and etcetera. “Tribal culture” is literally a metaphor for groups that emphasize the exclusion of outside members into their “cliques.” In the movie “The Faces of Medical Error…from tears to transparency – The Story of Lewis Blackman”, there was a lack of communication and no transparency between different departments of the hospital. In Blackman’s case, the tribal culture led to the nurses failing to communicate vital health information to the physicians and patients, which eventually led to Blackmans death. So whether there are cliques of nurses, physicians, or even sub groups within each, the presence of them suppresses teamwork and collaboration. This will ultimately lead to compromised patient care, disgruntled staff, and high nurse turnover. Hook your themes here.
Background
Lewis Blackman was a fifteen year old boy whose death was triggered by the numerous errors caused by his healthcare professionals. He was suffering from a Pectus Excavatum, a non-life threatening condition. His mother, Helen Haskell, was attracted to an advertised surgery that boasted all the benefits of the procedure without proclaiming the risks. He checked into the Medical University of South Carolina Children’s Hospital on November 2nd, 2000, to undergo this “safe and minimally invasive” procedure. Complications arose following the surgery, but they were not communicated effectively within the nursing co...

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...iately discovered and the patient was fine, but had there been proper communication between the healthcare staff, such blunders could have been avoided altogether (Dolanksy, 2013).
Furthermore, there should be enough trust between the nurses and physicians where they can easily put aside their egos and ask for a second opinion when they have any doubts concerning a patient's safety. This was clearly exemplified when the nursing staff attending to Lewis Blackman failed to contact the physician when various side effects arose; instead they tailored the signs to fit the expected side effects. Even after Blackman’s health was deteriorating, the nurses remained in their “tribes” and never once broke out of it to ask for help. The entire hospital was built on strong culture of remaining in their tribes instead of having goals oriented towards patients care and safety.