By, Katie Leander
The Josie King Story is hard to hear, but it should be heard by every care giver and every institution. Quite simply, this story can provide a paradigm shift in how care givers view medical errors and the impact of even seemingly small errors.
Josie was a little girl who died at 18 months of age at Johns Hopkins, just a couple of days prior to her scheduled discharge. She didn’t die due to a major, egregious error. As Josie’s mother, Sorrel says, Josie’s death was “…not the fault of one doctor, or one nurse or a misplaced decimal point.” Instead, she died from a series of smaller benign errors that together, proved too much for this child to bear.
While Josie died from severe dehydration and misused narcotics –she really died from errors and breakdowns in communication. But how could such errors kill a child? The video details the series of events, many of the errors, and the many times Sorrel spoke up on her child’s behalf, but was not listened to.
Sorrel offers several suggestions of how we can begin to improve the health care system and prevent such senseless deaths.
Listen to a concerned parent. Parents should be viewed as experts on their child and seen as an asset to the team. Their instincts should be trusted. If a parent expresses concern, it should be considered thoughtfully and addressed by the team –not dismissed. Often, parents can detect subtle changes in their child even before they are picked up by vital signs, tests, etc.
Observe the child. As Sorrel says, “…not all the answers are on your clipboard.” By this, don’t simply rely on data or vital signs that say the child is ok. Look at the child, use common sense, and ask, “Is this child really ok?”
We must acknowledge that human errors have a human solution. Sorrel would like to see institutions acknowledge that errors occur, so that they can then work to address them. The Josie King website offers several tools for caregivers and institutions to begin to work in this direction. For more information, please visit the Josie King Foundation.
Please take 15 minutes, watch the video, and share it with a colleague. Doing so may save a life.