agree at some point that light bulb moment should have come to any one of the nurses involved in Lewis' care. Could it have come when Lewis stopped making urine? or when it took seven blood pressure monitors to obtain a pressure? All these steps were hard to listen to and is clearly seen as a failure to rescue. Although staffing has been related to failure to rescue, it does not seem to be the issue in this case. Inexperience and lack of critical thinking skills has been identified as the issue, the fact that these nurses had no experienced RN's to rely on for help was also disturbing. I also agree that provider intimidation and the fear of failure exist with the inexperienced RN. Patient safety can be directly affected by this fear and lack
