A Drink of Water
Meanwhile, down in Pediatrics, they were preparing the groundwork for the launch of the Josie King Patient Safety Program. Josie King was 18 months old when she was taken to Hopkins after being scalded in a bathtub accident in February 2001, a year before Pam’s encounter with the culture of safety.
“She healed well and within weeks was scheduled for release.” Josie’s mother, Sorrel, writes on her Website, the Josie King Foundation.
But something was wrong. Josie seemed to be very thirsty all the time, eagerly seeking moisture from any available source. Her mother deferred to the experts. Sorrell King knew her daughter was thirsty, and she wanted to give her water, but was told she couldn’t.
The little girl died from dehydration.
The Summer 2004 online issue of Hopkins Medicine features a story called “A Remedy of Errors,” an audacious work of public relations, which I predict one day will make it to the University of Spin as a textbook example of how to write when you’ve been handed a lemon of a story.
“Out of a deadly medical mistake at Hopkins Hospital sprang a patient-safety effort that has united a bereaved parent with malpractice lawyers, physicians and nurses.”
The story starts out with a visit to the home of Josies’ parents by the Director of the Johns Hopkins Children’s Center, Dr. George Dover: “What could he possibly say to this man and woman whose 18-month-old daughter had died at Hopkins just days earlier, not of some rare, incurable disease but of thirst?”
“We knew what had happened,” says Sorrell King. “We wanted someone to tell us why—why didn’t they listen to us when we said something was wrong with Josie, why didn’t they give her something to drink? We were involved with our lawyer then. We were going for it. If George had said, ‘We’re not sure what happened,’ we would have thrown him out.”
George knew what to say.
The Kings had hired Paul D. Bekman to represent them. Hopkins was faced with the nightmare prospect of a junkyard dog like Bekman holding the personal injury lawyer’s Straight Flush: a slam-dunk case involving the death of a child – a child of the upper middle class. “My husband, our lawyer and George were holding me back from going to the newspapers,” says Sorrell. Hopkins was quick to settle for an undisclosed sum and to help set up the King Foundation.
So when Doc Dover visited the King family at their home on that “windy March Sunday,” he was all contrition and generosity – not to say that it wasn’t genuine.
“Remedy of Errors” went on about how patient safety had always been a top priority for Hopkins Medicine, even before Josie King died in their care in such a potentially public manner.
As President of The Johns Hopkins Hospital back in 1999 Ron Peterson was a hard charging executive with an eye for innovation – and he had a special interest in patient safety because his father died by medical mistake. One day he read a report from the Institute of Medicine which detailed the sad state of patient safety in America. One hundred thousand people a year died from medical mistakes – and some of those tragic deaths might have been prevented. According to The Sun, Ron Peterson “understood the report’s call to action.”
A call to action! What was needed was a plan, a grand plan to make patient safety — not merely a top priority — but The No.1 Priority.
Two years later, as Josie King lay dying for want of a drink of water, Peterson and other Hopkins visionaries were “still hammering out their plans” for patient safety. What important business could have been Hopkins’ No.1 priority when Josie King arrived at the Emergency Room — while Ron Peterson and his team were holed up somewhere hammering out their master plan. What was the No. 1 priority at Johns Hopkins Medicine if it wasn’t the safety of the patients?
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The Baltimore Sun ran a feature story about the tragedy.
There was outrage:
“Josie died of a Third World disease — dehydration — in the best hospital in the world,” said Dr. Peter J. Pronovost, a Hopkins physician and patient safety expert, whose father had been the victim of a medical mistake. “How could that possibly happen? The answer is, we’ve created a system that’s allowed it to happen.”
There were mea culpas and calls for accountability:
“This is my hospital. This happened on my watch. This is my responsibility. I’ll get to the bottom of it,” Dr. George Dover said. Dover said what had happened to Josie was a “sentinel event” – an unexpected occurrence resulting in serious injury or death. He said a committee would review, as required, what had happened and recommend ways to correct any problems.
And, to demonstrate sincerity and a willingness to go the extra mile, Dr. Dover promised that the hospital would try not to cover anything up.
Proclamations were issued from on High:
“I want everybody in the hospital empowered to be able to pull a cord and stop the assembly line when they see something unsafe,” said Dr. William R. Brody, president of the Johns Hopkins University.
(Hopkins later had the cord pulled for them in a rare display of pique by the FDA on another matter.)
“By June 2001, four months after Josie died, Hopkins had finished its review and told Sorrel and Tony what they had known all along: Josie’s death had resulted from a total breakdown of the system. Three weeks into her recovery, the child had suffered devastating brain damage after her heart stopped because of severe dehydration. The medical staff hadn’t responded appropriately to the warning signs – her precipitous weight loss, severe diarrhea, intense thirst and lethargy,” according to the Sun.
Dr. Dover may have taken full responsibility for the tragic death of Josie King, but when the internal investigation finally got to the bottom of it all, they found that a temp nurse should take the fall: “the committee concluded that the temporary agency nurse tending to Josie the 
day her heart stopped should have been more aggressive in alerting physicians to the child’s symptoms.” Richard P. Kidwell, Hopkins’ managing attorney for claims and litigation, said “The information was there, but no one really put it all together.” Kidwell, who reminds me of Lionel Barrymore in “It’s a Wonderful Life,” later revealed that the committee’s investigation had determined that the desperately dessicated Josie King should have been given a drink of water.
However, as the Baltimore Sun said, out of tragedy sprang a passion for safety, and the desire for Johns Hopkins to become the leader in the field. The Josie King Foundation would light the way of safe passage for all the sick and injured in the dicey environs of John Hopkins Medicine.
