Collateral Damage: A Patient, a New Procedure and the Learning Curve

 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 the Josie King Foundation website.

But something was wrong. Josie seemed to be very thirsty all the time, eagerly seeking moisture from any available source. Sorrell King knew her daughter was desperately thirsty, and she wanted to give her water, but was told she couldn’t. She deferred to the experts.

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 Josie’s 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 exactly what to say.

The Kings had hired Paul D. Bekman, who is usually specialized in dealing with work injury lawyers in phoenix AZ.  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. Hopkins definitely wanted to stop the King family from “going for it.”

“My husband, our lawyer and George were holding me back from going to the newspapers,” says Sorrell. So when Doc Dover visited the King family at their home on that “windy March Sunday,” he was all contrition.  Hopkins was quick to settle with the Kings for an undisclosed sum and they agreed to help set up the Josie King Foundation. They did not do these things because it was the right thing to do. They did them because there was nothing else they could do.  There was no blaming the victim in this case. There were no consent forms or technicalities to hide behind.

They had killed a pretty little girl.

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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 Baltimore Sun, Ron Peterson “understood the report’s call to action.” What was needed was a plan, a grand plan to make patient safety not merely a top priority at the Hopkins—but The Number One Priority.

As Josie King lay dying for want of a drink of water two years later, Peterson and other Hopkins visionaries were “still hammering out their plans” for patient safety.

If patient safety wasn’t The Number One Priority at Johns Hopkins Medicine, what was?

It was and is the same number one priority of any business: to make money. And the business model is this: Aggressively projecting and protecting the image of being the best hospital in America, and using that reputation to attract patients, who are treated by underpaid and overworked students of medicine. The big names lure them in and the residents and interns, who covet the Hopkins name for their resumes, do the work for dirt metered out by corporate medicine.

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The Baltimore Sun ran a feature story about the Josie King tragedy.  Hopkins management responded with righteous outrage at their own failings, and a declaration of resolve to do better.

“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.”

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.

There were mea culpas and calls for accountability:

“This is my hospital. This happened on my watch,” said Dr. George Dover. “This is my responsibility. I’ll get to the bottom of it.” Dover said that what had happened to Josie was a sentinel event – an unexpected occurrence resulting in serious injury or death. He said a committee would be formed to review 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.

“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,” the Sun reported. “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.”

Dr. Dover may have taken full responsibility for the senseless 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 later revealed that the committee’s investigation had determined that the desperately desiccated 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 world leader in patient safety. 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.  And then…