Twenty-five years ago, 15-year-old Lewis Blackman died following elective surgery at a respected South Carolina hospital. Since he was placed in a suboptimal ward that was inadequate for his condition, his health worsened from a perforated ulcer and overwhelming infection, warning signs were missed, family concerns were not adequately escalated, and life-saving treatment came too late. His death became one of the most influential patient safety cases in American health care. It prompted important discussions about communication failures, resident supervision, patient advocacy, and the need to listen when patients and families recognize that something is wrong. Those lessons remain essential. But 25 years later, we continue to overlook another lesson from Lewis Blackman’s death: Patient safety depends not only on the actions of clinicians but also on the conditions under which they work.
Lewis Blackman’s surgery occurred late in the week. As his condition worsened, he was cared for during a period when attending surgical coverage was less available. He was placed in a pediatric oncology unit rather than a surgical unit. None of these circumstances alone caused his death. Yet together they formed part of an operational environment in which warning signs were more likely to be missed and escalation was more likely to fail. The uncomfortable question is whether such operating conditions have become less common or more common since Lewis died. The answer is clear: They have become far more common.
America’s hospitals today care for an older and more medically complex population. The aging of the baby-boom generation has increased demand for inpatient care. Emergency department boarding has become routine, staffing shortages persist, and many hospitals operate near capacity for extended periods. As a result, hospitals increasingly function under levels of operational pressure that would have been considered extraordinary a generation ago. Yet because these conditions have become commonplace, they are often accepted as normal. That normalization is dangerous. Most tragedies like Lewis Blackman’s never become nationally known. They occur quietly, one patient at a time, hidden within overcrowded hospitals where clinicians are working under immense pressure and subtle signs of deterioration are easier to miss.
There may be far more Lewis Blackman-like cases occurring today than when Lewis died, not because clinicians are less capable or less committed, but because the environments in which they practice have become increasingly difficult.
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Research has repeatedly linked high hospital occupancy, emergency department boarding, and operational congestion to delays in care, adverse outcomes, and increased mortality. Yet many hospitals continue to treat crowding as an unfortunate but unavoidable reality. In fact, much of it is manmade and avoidable. Many hospitals create occupancy peaks through their own scheduling practices. Elective admissions are often concentrated early in the week. Patients accumulate over subsequent days as they recover and remain hospitalized. Occupancy rises steadily, and by midweek hospitals frequently experience their highest census levels and greatest workload pressures. This is the message from “Don’t Get Your Operation on a Thursday.”
The consequences ripple throughout the organization. Emergency departments back up because inpatient beds are unavailable. Patients may be placed in units that are not suited to their needs. Communication becomes more fragmented. Clinicians spend increasing amounts of time managing logistical problems instead of focusing on patient care. Importantly, none of this means clinicians become less skilled, less caring, or less dedicated. It means they are being asked to perform under conditions that make failure more likely.
This leads to a difficult but inevitable conclusion: As long as hospitals continue to tolerate large, avoidable manmade peaks in bed occupancy, truly safe hospital care will remain unattainable regardless of how many other safety initiatives are implemented. Hospitals can improve handoffs, strengthen escalation protocols, expand safety reporting systems, and invest in training and technology. All of these efforts are worthwhile. But if clinicians are routinely working in overcrowded environments characterized by excessive workload and operational strain, those interventions will never achieve their full potential.
A fundamental principle of patient safety is that systems should be designed to support human performance rather than depend on heroics. Yet every day, hospitals ask clinicians to compensate for predictable operational conditions that should not exist in the first place.
The encouraging news is that occupancy peaks are avoidable. Hospitals in the United States and abroad have demonstrated that smoothing elective admissions across the week can dramatically reduce census peaks, improve patient flow, alleviate overcrowding, improve staff satisfaction, and strengthen financial performance. Most importantly, it creates a safer environment in which clinicians have the time, attention, and resources needed to recognize deterioration and intervene before patients are harmed.
If we accept that excessive occupancy peaks create unsafe conditions, then organizations dedicated to patient safety can no longer treat them as merely an operational inconvenience. Accrediting bodies, professional associations, patient safety organizations, and patient advocacy groups should make the reduction of avoidable census peaks a core patient safety objective. Eliminating avoidable occupancy peaks should be viewed no differently than reducing medication errors, preventing infections, or improving surgical safety.
For 25 years, discussions of the Lewis Blackman tragedy have focused appropriately on communication failures and clinical oversight. Yet those failures did not occur in isolation. They occurred within an operational environment that made them more likely. Twenty-five years later, perhaps the most important lesson is one we have yet to fully embrace: Hospitals cannot reliably deliver safe care while operating under conditions of predictable overcrowding. Until patient safety leaders address that reality, tragedies like Lewis Blackman’s will continue to occur, largely unseen, largely unreported, and far more often than most Americans realize.
Eugene Litvak is president and CEO of the Institute for Healthcare Optimization and an adjunct professor of operations management in the Department of Health Policy and Management at the Harvard School of Public Health. His work applies operations management science to health care delivery, helping hospitals improve patient flow, expand access, and enhance quality and safety.
He is the author of more than 60 publications on operations management in health care delivery organizations. He edited The Joint Commission’s patient flow books Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd Edition and Optimizing Patient Flow: Advanced Strategies for Managing Variability to Enhance Access, Quality, and Safety, and he led the organization’s first patient flow seminars.
Litvak served on three Institute of Medicine (now the National Academy of Medicine) committees: The Future of Emergency Care in the United States Health System, The Learning Health Care System in America, and Optimizing Scheduling in Health Care. A representative sample of his work is available through the institute’s publications, and his recent commentary includes “Washington’s 200 billion dollar health care blind spot.” He shares updates on LinkedIn.
