To Err is Human: A Mother’s Perspective


To mark the anniversary of the Institute of Medicine’s watershed report To Err Is Human: Building a Safer Health System, West Health is running a series of interviews with IOM committee members who helped produce the report, as well as other national health experts to examine what progress has been made in reducing medical errors in the US.

This week’s Q&A is with, Sorrel King, founder of The Josie King Foundation, who lost her eighteen-month old, Josie, because of medical errors.

Tell us what you think in the comments, or send us your stories about medical errors and interoperability at yourstory@westhealth.org.


Sorrel King Founder, The Josie King Foundation @JKFfoundation

Sorrel King
Founder, The Josie King Foundation
@JKFfoundation


Joe Smith: Ten years ago, U.S. Representative Patrick J. Kennedy introduced the “Josie King Act,” which was intended to transform the technological backbone of the American healthcare industry by 2015, enabling higher quality, better patient safety, and increased efficiency. Why was the bill unsuccessful?

Sorrel King: While The Josie King Act was unsuccessful, it significantly heightened awareness on patient safety. We understood that transforming the backbone of the healthcare industry would not be an easy task, and there was a long road ahead of us. Organizations are moving in the right direction and making great strides to transform healthcare, but there are still many components that need to come together to improve the care of our patients. I believe the main focus has to be on communication and transparency. We all need to strive to create a culture of openness and transparency in our hospitals by recognizing or rewarding those who prevent hospital errors and share those stories so others can learn from them.

JS: Despite an order for no more narcotics, Josie was given an injection of methadone, authorized by a different physician. Our healthcare system has failed Josie, your family and many others. Looking back, do you think that better technology—and more specifically, having interoperable medical devices—would have saved Josie?

SK: Yes, better technology and interoperable medical devices are an important consideration. Enabling medical devices to connect and communicate would reduce errors and provide better care. In my opinion, communication and teamwork are the most critical missing pieces to solve this puzzle in healthcare. We need to focus on listening to the patient/family, encouraging them to speak up and ask questions; improving patient/doctor communication; improving teamwork; and encouraging caregivers to look for those “near misses” before harm comes to the patient. A truly interoperable system would support this communication and teamwork, and could definitely provide another level of patient safety when there are potential mistakes.

JS: It’s now almost 2015—the year given as a deadline for the transformation of technology championed by the legislation. What has improved and what still needs be done? What policies would a new Josie King Act address or change? What role does the federal government play in combating medical errors? What entity should oversee medical errors?

SK: We can’t wait around for the government to figure this out. All stakeholders need to come together to combat medical errors and improve patient safety for all. Everyone has a part to play. The statistics on medical errors are no better today than they were when the IOM report was released. While disappointing, the numbers do not make me or The Josie King Foundation any less optimistic. We will continue to our important work to prevent others from dying or being harmed by medical errors.

There is no one entity that will be able to oversee what is happening in hospitals across the country. It has to come from within each hospital and each individual caregiver. The importance of the work to improve patient safety has to be highlighted and rewarded. Perhaps, a little less focus should be placed on what is being done wrong with more value placed on what is being done right. When an organization recognizes what they’re doing right, they can get rid of old policies and practices and move toward new models that result in better care of their patients and families. Hospitals that come together and share their experiences, both good and bad, will help others learn, move forward and improve care.

Transparency has to be the goal. Errors have to be reported for improvements to be made. There is a role for interoperability to play here in ensuring that we can identify medical mistakes and “near misses.” At the moment we are only able to identify a range of how many deaths happen from preventable medical mistakes. It’s impossible to make improvements without data on where potential problems exist.

Ultimately, our efforts are focused on raising awareness and preventing others from dying or being harmed by medical errors. By working to unite healthcare providers and consumers, and through funding innovative safety programs, we hope to create a culture of patient safety and encourage everyone to join us in our efforts.

JS: The Josie King Foundation’s mission is to prevent others from dying or being harmed by medical errors. What is the foundation currently working on? What are its priorities?

SK: The priorities of the Foundation remain true to our original mission – to prevent patients from dying or being harmed by medical errors. By uniting healthcare providers and consumers and funding innovative safety programs, we hope to create a culture of patient safety together. We work hard to create projects and programs that are inspirational for the caregivers of the future – ones that empower those who dedicate themselves to taking care of all of us.

This year, the Foundation released a new educational tool: Josie’s Story: A Patient Safety Curriculum. It was created with the fundamental understanding that facts provide us with knowledge and stories provide us with wisdom. The curriculum was created by a team of educators from the Duke University Health System. Together, we set out to form a patient safety tool that combined the power of story and the science of safety with interactive and meaningful educational material. It was designed to be utilized in many different settings including medical and nursing schools, in addition to hospitals and healthcare systems that are in need of educational and inspirational patient safety material. Our hope is that these materials will provide knowledge and wisdom as caregivers go forth into the world of healing.

Another exciting project we recently launched is the Hero Award. The award was created to recognize a caregiver who is dedicated to creating a culture of patient safety through listening to the patient/family; encouraging them to speak up and ask questions; improving communication and teamwork; looking for the good catches (near misses); and fixing those near misses before they harm a patient. These awards are to celebrate those who set an example for others every day and inspire positive change.

Hospitals, nursing/medical schools and other organizations can partner with the Foundation to implement the Hero Award program at their organization. Organizations can determine which caregivers are the patient safety heroes of their team. This is a great way to celebrate their dedication to improving a culture of patient safety, boost internal morale and encourage others to put patient safety first.

In addition, we created The Josie King Hero Pins for any and all healthcare providers who share their “good catch” story with the patient safety/quality team at their hospital. The purpose is to help support a culture where caregivers are recognized and rewarded for finding the near misses, reporting them and fixing them. These pins are our way of thanking caregivers for creating a culture of patient safety. We hope many caregivers will wear these very special pins proudly on their lapels.

The Foundation continues to provide these educational materials and awards on a weekly basis to hospitals, medical schools, nursing schools and individuals. In addition, our free Care Journal app is downloaded to mobile devices across the world on the monthly basis.