Do you Know Who Josie King Is? You Should.

Every health care provider should learn about Josie King and her story. A lot of times, when we think of medical errors that result in death, we think of errors that are major and dramatic. But this was not the case with Josie King. Josie King was an 18-month old little girl who died from not one major error committed by one individual, but from a series of small, preventable errors made by many caregivers.

How could this happen? Moreover, how could this happen to a child who was supposed to go home from the hospital within 48 hours? Suffice it to say, everyone should see the Josie King video and learn about the Josie King Foundation.

Josie’s story illustrates why patient safety is important on all levels, with all decisions, and regarding every patient interaction. Josie’s story illustrates several seemingly benign breakdowns in the health care system: primarily breakdowns in communication, including physicians and nurses not listening to a parent –all avoidable, yet small errors. But, together, this series of small errors turned into a lethal combination that was too much for this child to handle.

While we often talk about errors in medicine on this blog, a lot of times we talk in a theoretical way. And although Josie’s story is awful and hard to hear, it is important that it be told, because it puts a human face on medical errors and it makes the discussion more real. As a mother, myself, of a medically complex child, I totally related to Josie’s mother, Sorrel. Sorrel was a competent woman: she was involved in the care of her child, knew her child well (and what was “normal” and “not normal” for her child) and was not afraid to speak up on her daughter’s behalf. She did everything “right” –and her child still died.

While there were several kinds of errors in Josie’s case, I thought Sorrel offered a gem of information. Considering that parents (and other family members) don’t want to see an error as much as health care providers don’t, she suggests that parents can be viewed as a resource to alert health care providers to potential “red flags.” Doing so can potentially help caregivers avoid or minimize other errors –or, in this case, help prevent a child from dying.