A patient safety seminar was presented by Sigma Theta Tau, international nurses honor society, to Tech nursing students last Tuesday. Sorrel King, author of “Josie’s Story,” spoke about the death of her daughter because of medical error.Speakers prior to King highlighted issues mentioned in King’s speech. Joy Wachs’ presentation, “Culture of Safety,” emphasized the importance of culture in hospitals, and Belinda Mandrell spoke on “End-of-Life Decision Making.”
“I looked at her and all-of-a-sudden something just didn’t look right to me. Her coloring seemed kind of off,” King said, “It was something about her eyes, like she was falling asleep or something. She became really lethargic. Her eyes were rolling back in her head.”
King described to a room of about two hundred nursing students and staff the tragic death of her 18-month-old daughter, Josie. Josie King was admitted to John Hopkins Hospital with first- and second-degree burns after climbing into a hot bath. Her death, however, was because of faulty communication between nurses and doctors.
Bedelia Russell, assistant professor of nursing, said she hopes Josie’s story will impact students by teaching them how important nurses are in preventing this type of harm to patients through errors and breakdowns in communication.
King said numerous times throughout her speech that she repeatedly told the nurses and doctors something about Josie “just didn’t look right.”
Junior nursing student, Magen Jones said, “Josie’s death could have been prevented. One of the most important things I learned from this seminar was to listen when patients say ‘something just doesn’t look right.’ It is imperative that we as nurses take the families’ concerns seriously and look into what is causing the family members to suddenly become uncomfortable.”
In Josie’s case, she was dehydrated and the nurses were missing the signs, even with the vocalized concern of King. King was instructed not to give Josie anything to drink, only ice chips.
“I kept telling the nurses that Josie was thirsty,” King said, “but they kept assuring me her vitals were fine. They convinced me to go home that night, but when I returned the next morning I walked into her room, took one look at her and screamed for help.”
The nurses told King that other patients needed assistance and Josie would have to wait.
“I wanted to be low maintenance. I didn’t want to ask too many questions. I didn’t want to bother the nurses or doctors. I just wanted to be a nice, quiet, helpful mother, but at that point I screamed for help.”
Nursing student Meghan Herren, said, “What I learned most from Josie’s story is [nurses] really need to encourage family members to speak up about issues and ask questions. Most nurses do not mind if family members ask questions because nurses are there to be advocates for the patient.”
The nurses gave Josie a drink and a shot of Narcan. King said Josie immediately appeared more alert. She also inquired if Josie would receive her 1 p.m. dose of the pain medication, Methadone. King advised the doctor she was doing fine and was no longer in any pain. The doctor then gave verbal orders for no methadone to be given. However, at 1 p.m. a nurse showed up with a syringe of Methadone. She informed King that the orders had been changed.
Wachs said that the culture of a hospital is “how we do things around here.” Culture is often difficult for members to define.
“An organization’s culture of safety depends on health care workers feeling they are treated fairly and listen to by supervisors,” Wachs said, “and how well health care providers work as a team, get along, and feel they can talk to each other about safety.”
Following the nurse’s administration of the methadone, Josie went unconscious. The next time King saw her daughter she was on life support.
Jones said “Wachs’ presentation showed us that errors do not necessarily occur because of an individual, but as result of an error in the healthcare system. Although it is not easy to change our culture, [nurses] should strive to make improvements in the system to protect our patients.”
King said, “My thought and something I will have to live with for the rest of my life was, ‘Do I run up to that nurse, knock the methadone out of her hand, run out and scream for help or do I say to myself that John Hopkins is probably the best hospital in the world. These doctors, these nurses, they are smarter than I am? They must’ve decided together that for some reason that I couldn’t understand, Josie needed that medicine.'”
Mandrell spoke on the importance of including adolescent patients in major healthcare decisions.
Ashton Clouse, Sigma Theta Tau chapter president, said, “As a researcher at St. Jude Children’s Research Hospital, Dr. Mandrell has extensively studied the significance of allowing pediatric patients to be involved in end-of-life decisions, which arise with terminal illnesses. This reminded all of us to ask the pediatric patient for input in their care.”
The following day, a team of neurologists explained to King that Josie had no brain stem function and would not survive.
King said, “In 24 hours, we had gone from planning a welcome home party to planning a funeral. Our lives were turned completely upside-down. We were pretty much consumed by two emotions, grief and anger. For the weeks and months after she died, I would literally pace around my house. I would walk back and forth in my bedroom, in the halls of my house, shaking my head like a crazy person.”
King said she questioned how something as simple as communication cost her daughter’s life. John Hopkins hospital offered a formal apology to the family in their home in the weeks following the tragedy. After months of working with lawyers and struggling with the choice of accepting the settlement money or refusing it, the King family finally decided to start a foundation with the money.
King started up the Josie King Foundation. The foundation’s goal is to help patients and healthcare providers communicate effectively to prevent errors in healthcare.
Clouse said, “I hope our guests renewed their commitment to providing safe and competent care to our patients.”
The event ended with a book signing by King. For more information about Josie King’s story or to donate to the Josie King Foundation, visit www.josieking.org.