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1. Identify at least one instance where you believe an error in patient safety occurred. 

2

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The Question

1. Identify at least one instance where you believe an error in patient safety occurred. 

2. In your opinion, what is one thing the nurse could have done to prevent the error?

3. Which ethical dilemmas (not necessarily in this story) are you most concerned about facing in your nursing practice?

A Fight Against Fatal Error

 

Josie 'should not have died,' the hospital's attorney

 

conceded.

 

By

 

Laura Landro

 

Updated Sept. 7, 2009 7:46 p.m. ET

 

Wall Street Journal After her 18-month-old daughter, Josie, died from complications of treatment at Johns Hopkins Medical Center in

 

early 2001, Sorrel King was bent on vengeance: She wanted to take the hospital apart "brick by brick" and ruin the

 

doctors and nurses responsible for the loss of her baby.

 

But in the end she took another path, joining forces with her adversaries in a bid to make medical care safer for

 

patients. In "Josie's Story," a wrenching but inspiring memoir, Ms. King details her journey from grief to activism. With

 

a chunk of money from a legal settlement, she created a patient-safety program at Hopkins and a foundation devoted

 

to reducing medical errors. For the past few years she has been a passionate advocate for patients, lecturing medical

 

professionals about the devastating effects of slipshod care.

 

Medical errors are estimated to kill as many as 98,000 patients a year in the U.S. Patients die from the wrong drug or

 

the wrong dosage, from infections that could be prevented with simple hygiene and from complications that could be

 

prevented with better oversight. As Ms. King notes, the problem is often not a single doctor or nurse or a misplaced

 

decimal point on a medication vial but rather faulty systems and communication breakdowns. Peter Pronovost, a Hopkins intensive-care expert who became Ms. King's partner on the stump, calls it "the Swiss cheese effect." There

 

are so many potential places for error that "when the holes all line up," he says, "the errors get through the system

 

and the patient dies." (He speaks from personal knowledge: His own father died after a medical mistake.)

 

The King tragedy begins to unfold when Josie, the youngest of four children, wanders into the bathroom one chaotic

 

day as the family is moving into a new house in Baltimore. Alone for just a few moments, she turns on the water in the

 

bathtub, where she liked to float her toy airplane. When she steps into the tub, scalding water causes second- and

 

third-degree burns over 60% of her body. Her screams summon her panicked parents, a 911 call is made and Josie

 

is soon in the care of the burn center at Johns Hopkins Bayview Medical Center.

 

The Kings are subjected to a child-abuse inquiry and made miserable by the thought that they let their daughter out of

 

sight long enough for such an accident to happen. They are cleared?the hot-water heater is found to have a faulty

 

mechanism that set the temperature at 150 degrees. After a transfer to Hopkins's pediatric intensive-care unit, Josie

 

is on the road to recovery.

 

But then things go awry. Ms. King notices that Josie seems especially thirsty, but the nurses and doctors don't seem

 

to think it is a problem. When an unfamiliar nurse comes into Josie's hospital room to administer a dose of

 

methadone as a painkiller, Ms. King protests that she heard a doctor give a verbal order that no narcotics were

 

needed, but it is given anyway. Josie's thirst appears to worsen, but her vital signs seem fine, and no one heeds her

 

mother's concerns about dehydration. At the bedside, Ms. King suddenly sees her daughter's eyes roll back into her

 

head and calls for help as the child goes into cardiac arrest and can't be rescued. All that is left is for Josie's parents

 

to have her baptized before the life support is turned off. She dies in their arms.

 

In the hospital business, Josie's death was what is known as a "sentinel event"?an unexpected death or serious

 

injury that must be investigated. The hospital's chief attorney, Rick Kidwell, invites Ms. King to recount her version of

 

events at the hospital's analysis meeting. She is stunned to learn that the final methadone dose was ordered by a

 

doctor as part of a diminishing-dosage strategy to wean Josie off the drug. The hospital says that the drug didn't

 

cause the cardiac arrest, but we never really understand what happened; all the officials can tell her is that there were

 

"complications." The hospital should have listened to Ms. King's pleas, and Josie "should not have died," Mr. Kidwell

 

admits. (Hopkins, for its part, has not publicly challenged Ms. King's version of events and says that it is proud to

 

work with her on patient-safety programs.)

 

The Kings refuse an early settlement offer but in the end decide that the money can serve a higher goal, ensuring

 

that "every hospital in the country knows [Josie's] name and why she died." Mr. Kidwell gives Ms. King the go-ahead

 

to air Hopkins's dirty laundry and arranges for her first public speech about Josie?at Hopkins's own grand rounds for staff. The amphitheater is standing room only, a sea of white coats, scrubs and business suits. Ms. King sees, at this

 

event and others, that health-care professionals suffer, too, from error incidents. They are terrified "that they might be

 

the one at the end of the line who administers the drug with the wrong dosage or signs off on a treatment given to the

 

wrong patient."

 

Ms. King finds many champions. Charles Denham, a doctor with his own patient-safety organization, videotapes a

 

speech that she gives to the Cambridge, Mass.-based Institute for Healthcare Improvement. He makes DVDs from it

 

so that she can provide them to hospitals in return for a donation to the Josie King Foundation. When Don Berwick,

 

the charismatic leader of IHI, launches a campaign to "save 100,000 lives" at another conference, Ms. King stirs the

 

audience to take up the cause. When the University of Pittsburgh Medical Center sets up a program to let families call

 

for a "rapid response team" if they feel a patient is not getting proper attention, Ms. King funds part of its pilot project. Mom?s presentation:

 

http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/WhatHappenedtoJosieKing.asp

 

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