Case Study: The Goal Is to Communicate

Johns Hopkins is a world leader in medicine. So when Sorrel and Tony King found themselves there in 2001 with their 18-month-old daughter, Josie, they were grateful. Josie had climbed into a bathroom tub, turned on the hot water and scalded her tiny body with first- and second-degree burns. Doctors treated her with medications and skin grafts; slowly, she began to heal. But just days before she was expected to be released, Josie's condition took a sudden turn for the worse. She became incredibly thirsty--sucking on a washcloth after a bath--and her eyes rolled back in her head. "I screamed for help," says Sorrel, but she was told not to worry--her daughter's vital signs were fine. Then a nurse gave Josie a shot of methadone, despite Sorrel's protest. She'd been assured that no more medications would be given; the nurse said the orders had changed. Sorrel told herself: "These people are a hell of a lot smarter than I am and they know what they're doing."

Nobody can say for sure what role, if any, the medication played, but the hospital later concluded that Josie was severely dehydrated. And one thing was clear: a mother's concerns had been repeatedly overlooked. On Feb. 22, 2001, after her heart stopped and she suffered irreversible brain damage, Josie was taken off life support. "In my mind and I think in the minds of everyone who cared for Josie, it was a huge communications breakdown," says Sorrel.

In the aftermath of Josie's death, the head of Hopkins Children's Center took the unusual step of visiting the Kings at home and apologizing. But sorry wasn't enough. The Kings wanted to be sure that what happened to Josie would never happen again. "It was so unimaginable," says Sorrel. "We weren't about to let Hopkins off the hook." Rather than sue, the Kings settled for an undisclosed amount, then donated a portion of the money right back to Hopkins, establishing the Josie King Patient Safety Program.

Today Sorrel works closely with Hopkins, an institution now adamant about open communication. "We pay an awfully high price for silence in health care," says Dr. Peter Pronovost, medical director of Hopkins Center for Innovation in Quality Patient Care. Parents are encouraged to be vocal participants in their children's care--a direct outgrowth of the King's experience. Drug doses go through multiple checks, from doctor to pharmacist to dispensing nurse. And, using a program called CUSP (Comprehensive Unit-based Safety Program), Hopkins has a no-fault approach for its employees. Higher-ups actively seek out hazards, talking routinely to staffers throughout the hospital about their concerns. On one recent round, a nurse slapped down vials of two different asthma medications for kids, explaining that the colors on the packaging had suddenly been swapped--a recipe for confusion and disaster. "Within 24 hours, the entire product had been pulled," says Dr. Marlene Miller, director of quality and safety at Hopkins Children's Center.

Docs and nurses fill out daily goal forms for patients to be sure that no step in their care is overlooked. And medical students, who learn little about how to deal with medical errors in school, shadow nurses. The hope, says Pronovost, is that students will be prepared to work collaboratively with other staff members, rather than harbor know-it-all attitudes. Already, he has seen improvements: students trained several years ago "are now communicating much more effectively."

Neither Sorrel nor Pronovost are keeping the culture to themselves. Together, they are taking CUSP, which has been shown to improve safety, nationwide. And they're meeting with medical students, speaking at health conferences, visiting hospitals. Josie's story has stirred other institutions to pay more attention to the people they serve. At Shadyside, a hospital in Pittsburgh, administrators have adopted a program inspired by Sorrel called "Condition H," which allows parents and family members to call for help from doctors or nurses when they are seriously concerned about a patient's condition. "The bottom line," says Sorrel, "is that it would have saved Josie." Today, Josie is no doubt saving others.