• Step 1: 1. Read the Bates and Singh (2018) article from Week 4 for background

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• Step 1:
1. Read the Bates and Singh (2018) article from Week 4 for background on patient safety progress in the last
two decades.
2. Review the Marx (2001) article from Week 3 to develop deeper understanding of Just Culture in Healthcare.
3. Review the Paradiso & Sweeney (2019) article to inform the nursing perspective of Just Culture.
4. Consider what you learned in Week 3 through completion of the QSEN modules.
• Step 2: Write down the initial post DB prompts before viewing the Lewis Blackman case
a. Identify three errors that occurred in the Lewis Blackman case.
b. Categorize the errors using the Marx (2001) definitions of “The Four Evils” (pp. 5-7).
c. Consider one of the errors you have identified. Was there one step a nurse in the case could have taken to
avert harm to Lewis? If so, briefly describe what the nurse could have done to reduce harm (consider the Swiss
Cheese Model).
d. Practice using healthcare safety terminology learned in this course and previous courses.
• Step 3: Post your summary of Un-safe Healthcare in the United States DB by Wednesday. For full credit the
initial posts require inclusion of support from the course materials (cited and referenced).
Please limit the initial post to approximately 500 words. Students will also need to include an APA reference list
at the bottom of your post to the extent possible in Bb DB format (i.e. no indenting or double spacing).

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