Sorrel King is an author, patient safety advocate, and president/co-founder of the Josie King Foundation. Her 18-month old daughter, Josie, died at Johns Hopkins Bayview Hospital of dehydration due to medical error after being hospitalized for second-degree burns. Following a financial settlement from Johns Hopkins, Sorrel King started the Josie King Foundation and wrote a novel about her experience entitled Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe.
Sorrel King had four children: Jack, Eva, Relly, and Josie. [1] She attended the University of Colorado where she met her husband and father of her children, Tony. The family originally lived in Richmond, Virginia before moving to Baltimore County for her husband's job as a stock-trader at Wachovia Securities. Sorrel King originally worked as a designer. She successfully started a women's clothing line that was sold at Barney's and Saks Fifth Avenue, among others. [1] After her daughter's death, she became an author and internationally-recognized patient safety advocate. She was founder and President of the Josie King Foundation. In 2008, she was awarded the PPAG Advocacy Award from the Pediatric Pharmacy Association for her advocacy work. [2]
On January 23, 2001, Josie King (18 months old) suffered an accident in a hot bath she accidentally drew for herself, which resulted in second-degree burns on 60% of her body. Sorrel King called an ambulance that took her to Johns Hopkins Hospital Bayview Center. [3] Her daughter was treated with skin grafts, intravenous fluids, and pain medications. Her daughter improved rapidly and was moved to the Intermediate Care Unit. [1]
Although her vital signs were normal and her burns continued healing, she developed a high fever, vomiting, and diarrhea. The blood, stool, and urine tests the doctors conducted came back with no indication of another underlying illness. The doctors decided her central line, through which her fluids were being administered, could have an infection and subsequently removed it. Her daughter's condition worsened. Josie began to suck on the washcloth when given her bath and at night, her eyes began rolling back into her head. [1]
Sorrel attempted to give her daughter fluids but the nurse warned against it and explained that her vital signs were normal. Sorrel asked for a physician to come see her daughter and her request was denied. Sorrel returned to the hospital at 5:30 A.M. and found her daughter in worse condition. The doctors gave Josie a shot of Narcan and ordered that no more narcotics be administered. Josie immediately began recovering.
The narcotics team worried that Josie would experience withdrawal and suggested that a smaller dose of narcotic should be administered. The surgeons on duty were consulted and it was agreed that a dose would be administered, despite Sorrel’s concerns. The nurse explained to Sorrel that the order had been changed, and the nurse administered a shot of methadone. Sorrel's daughter's condition worsened until she was rushed to the Pediatric Intensive Care Unit where she suffered a cardiac arrest as well as extensive brain damage after her heart stopped. [4] Despite revival efforts, Josie King passed away that evening of February 22, 2001.
An investigation from the hospital concluded that Josie King's cardiac arrest was caused by severe dehydration and that the warning signs -- diarrhea, extreme thirst, weight loss, etc. -- had not been taken into account in Josie's case.
Johns Hopkins Hospital accepted full responsibility for the death of Josie King and offered the family a financial settlement. [5] Dr. Peter J. Pronovost, a Johns Hopkins physician whose father had died due to medical errors, allied with Sorrel King and helped her establish her foundation as well as implement the Josie King Patient Safety program at Johns Hopkins. [4] Sorrel King funded the program with $50,000 of her initial financial settlement, and then raised $200,000 more through her foundation. [4] The program at Johns Hopkins hoped to revitalize the hospital's medical training with improved patient safety standards and a commitment to reducing and reporting medical errors. [3]
The Josie King Foundation's main goal was to prevent harm to patients from medical errors. The foundation promoted speaking appearances, safety training programs, community outreach, among others. The foundation started the Josie King Hero Awards Program, which rewards any member of hospital staff that acknowledged, reported, or prevented a medical error. [3] A video of Sorrel King's speaking appearance at an Institute of Healthcare Improvement (IHI) meeting was shared internationally to hundreds of hospitals and healthcare organizations. In the speech, King recounts the story of her daughter and suggested that parents should be able to call on the rapid response team if the patient's condition seems to worsen. [6] [7] Following this speech, and with support from the foundation, Condition H was implemented at UPMC-Shadyside Hospital. Condition H, where the H stands for help, is an established protocol that will enable patients, their families, or their visitors to initiate a rapid response call if there is perceived danger to the patient's health. [8] [9] This protocol was then implemented in hospitals throughout the nation.
Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe is an autobiographical novel written by Sorrel King published by Grove Atlantic in 2009. [10] Her novel was named one of the Best Health Books of 2009 by the Wall Street Journal, [10] and nominated for a "Books for a Better life" Award from the Multiple Sclerosis Society. [11]
In 2004, Representative Patrick J. Kennedy introduced the Josie King Act (also referred to as the Quality, Efficiency, Standards and Technology for Health Care Transformation Act of 2004, or the QUEST Act), which was intended to improve sharing and distribution of secure medical information between healthcare providers and patients on a national level. [12] [13] The bill died without receiving a vote in the 108th Congress. [14]
Sorrel King made appearances on Good Morning America and NBC Nightly News with Tom Brokaw as well as in an article entitled “Fixing Hospitals in 2005.” for Forbes magazine. [8]
An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center.
A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.
Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients under his or her care.
The Portland Hospital for Women and Children is a private maternity hospital on Great Portland Street, City of Westminster, London, England, owned by the Hospital Corporation of America.
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.
A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery
Johns Hopkins Bayview Medical Center is teaching hospital trauma center, neonatal intensive care unit, geriatrics center, and is home to the Johns Hopkins Burn Center, the only adult burn trauma in Maryland, containing about 420 beds. Located in southeast Baltimore City, Maryland, along Eastern Avenue near Bayview Boulevard, it is part of the Johns Hopkins Health System and named after its close proximity to the Chesapeake Bay. Founded in 1773 as an almshouse, it was relocated several times until its now present location in 1866. In 1925, it transitioned into several municipal hospitals, which transferred ownership to Johns Hopkins Hospital in 1984.
Peter J. Pronovost is Chief Quality and Transformation Officer at University Hospitals Cleveland Medical Center, the main affiliate of the Case Western Reserve University School of Medicine. At UH, Pronovost is responsible for improving value across the health system, helping people stay well, get well and manage their most acute medical conditions. He is the clinical lead for population health and the lead for high-reliability medicine, with direct responsibility for the UH employee accountable care organization. He is also responsible for telehealth and virtual health programs serving patient and provider communities.
Lisa A. Cooper is an American internal medicine and public health physician who is the Bloomberg Distinguished Professor of Equity in Health and Healthcare at Johns Hopkins University, jointly appointed in the Johns Hopkins School of Medicine, Johns Hopkins School of Nursing and in the departments of Health, Behavior and Society, Health Policy and Management; Epidemiology; and International Health in the Johns Hopkins Bloomberg School of Public Health. She is the James F. Fries Professor of Medicine in the Division of General Internal Medicine, Director of the Johns Hopkins Center for Health Equity, and Director of the Johns Hopkins Urban Health Institute. Cooper is also a Gilman Scholar and a core faculty member in the Welch Center for Prevention, Epidemiology, and Clinical Research. She is internationally recognized for her research on the impact of race, ethnicity and gender on the patient-physician relationship and subsequent health disparities. She is a member of the President’s Council of Advisors on Science and Technology (PCAST). In 2007, she received a MacArthur Fellowship ”genius” grant from the MacArthur Foundation.
Martin Adel Makary is a British-American surgeon, professor, author and medical commentator. He practices surgical oncology and gastrointestinal laparoscopic surgery at the Johns Hopkins Hospital, is Mark Ravitch Chair in Gastrointestinal Surgery at Johns Hopkins School of Medicine, and teaches public health policy as Professor of Surgery and Public Health at the Johns Hopkins Bloomberg School of Public Health.
Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.
A rapid response system (RRS) is a tool implemented in hospitals designed to identify and respond to patients with early signs of clinical deterioration on non-intensive care units with the goal of preventing respiratory or cardiac arrest. A RRS consists of two clinical components and two organizational components.
Patient record access in the United Kingdom has developed most fully in respect of the GP record, because computerisation in that field is almost universal. British hospitals were slower to move into electronic records. From 1 April 2015 all GP practices in England have to provide online services to patients, including access to summary electronic medical records.
Suzanne Gordon is an American journalist and author who writes about healthcare delivery and health care systems and patient safety and nursing. Gordon coined the term "Team Intelligence," to describe the constellation of skills and knowledge needed to build the kind of teams upon which patient safety depends. Her work includes, First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, a collection of essays edited with Ross Koppel and Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork, written with commercial pilot Patrick Mendenhall and medical educator Bonnie Blair O’Connor, with a foreword by Captain Chesley "Sully" Sullenberger.
Surfing the Healthcare Tsunami: Bring Your Best Board is a made for television documentary that explores medical errors and waste in healthcare. It was broadcast globally on the Discovery Channel in 2012. It references federally-funded studies in the United States and news footage to support the claim that healthcare workers are afraid to speak up when medical errors occur in hospitals. The documentary covers solutions to preventable system failures causing harm. It aired four times on the Discovery Channel commercial-free in North America, Germany, the U.K., France, and other Western European countries including Sweden. It premiered at the National Press Club on April 27, 2012, after a short speech by Captain Sully Sullenberger who was featured in the film. The film was screened at the Texas Health Care Quality Improvement Awards on May 3, 2012.
Bleed Out is a 2018 HBO feature documentary film that explores how an American family deals with the effects of medical malpractice. The film revolves around a ten-year journey, captured through archival footage, spy-cams, and interviews. Writer-director Steve Burrows reveals the ways his mother, Judie Burrows, was afflicted for the rest of her life due to a mistake during a partial hip surgery procedure.
Kelly Anne Gebo is an American epidemiologist and infectious disease specialist. She was the inaugural Vice Provost for Education at Johns Hopkins University and served as the Chief Medical and Scientific Officer for the All of Us Research Program at the National Institutes of Health.
Annegret Friederike Hannawa is a German communication scientist and founding director of the Center for the Advancement of Healthcare Quality and Safety (CAHQS) at the Università della Svizzera italiana in Lugano.
Kathryn McDonald is an American scientist who is Bloomberg Distinguished Professor at the Johns Hopkins University. She serves as co-director of the Johns Hopkins Center for Diagnostic Excellence. McDonald previously led the Centre for Health Policy at Freeman Spogli Institute for International Studies. Her research considers what makes for high-quality and safe healthcare delivery systems.
State of Tennessee v. RaDonda L. Vaught was an American legal trial in which former Vanderbilt University Medical Center nurse RaDonda Vaught was convicted of criminally negligent homicide and impaired adult abuse after she mistakenly administered the wrong medication that killed a patient in 2017. She was sentenced to three years' probation.
