TY - CHAP M1 - Book, Section TI - Engaging Patients and Families A1 - Frush, Karen S. A1 - Krug, Steven E. PY - 2015 T2 - Pediatric Patient Safety and Quality Improvement AB - 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. SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/03/28 UR - accesspediatrics.mhmedical.com/content.aspx?aid=1105561589 ER -