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Introduction

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In the year 2001, a little girl named Josie King died from medical errors. Josie became the face behind the staggering statistic—98,000 deaths from medical errors every year, the face behind the reality that this simple five-digit numeral translates into the disturbing visual of a jumbo jet crashing every day. Perhaps it was the culmination of events that led up to her death, along with the fact that those events took place in one of our country’s finest hospitals, which caused the healthcare industry to pause and take a good long hard look at itself. Josie was admitted to the prestigious Johns Hopkins Hospital after she suffered from burns upon climbing into a hot bath. Two days before Josie was to come home, she died from severe dehydration and misused narcotics. It was not a doctor’s mistake, a nurse’s mistake, a misplaced decimal point, or an incorrect medication that led to her death. Josie died from a breakdown in communication, a breakdown in the system. What if the residents had noticed that her weight had dropped significantly in 24 hours? What if someone had listened to Josie’s mother as she repeatedly told the staff that her daughter was really thirsty? What if there had been better communication between the doctor who changed the methadone order and the nurse who didn’t realize the order had been changed? Perhaps if Josie’s mother had been able to call a Rapid Response Team or if the doctors and nurses had taken their eyes off of the computer screens and clipboards and looked at the little girl, she would be alive. Maybe if someone had listened to Josie’s mother as she repeatedly asked for help, none of this would have happened.

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At the time of Josie’s death, hospitals and healthcare providers across the country were grappling with the findings released in a November 1999 Institute of Medicine report, “To Err is Human.” This report forced well-meaning, highly committed healthcare professionals to confront the fact that, despite their best efforts, every day patients are harmed and even killed in healthcare settings across the United States. The burning platform became evident, and the “patient safety movement” was launched.

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Individual patient safety champions, private organizations, and the federal government began the hard work of redefining patient safety and transforming the traditional healthcare culture. Over the past decade, we have come to realize that, rather than “freedom from accidental harm,” patient safety is a “discipline that utilizes a systems approach to improving healthcare processes and outcomes.”1 It has become clear that the complexity of modern healthcare has surpassed the capability of any individual provider, and patient safety requires a shift from focusing on individual performance to high-performing teams. Essential to this shift is the inclusion of patients and families as members of these teams and engaging them in all aspects of care delivery, from redesigning care processes and reimbursement models to training the next ...

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