Human error plagues hospitals, speaker says

Published in the University of Delaware -The Review, March 8, 2016. – In January 2001, 18-month-old Josie King was admitted to the Johns Hopkins Hospital as a result of suffering third degree burns from a hot bath.  Within weeks she healed and was scheduled to be released. Two days before Josie was scheduled to go home, the young toddler died as a result of careless human medical error…


Read More

Hospital rapid response teams can save lives

Published in: The Philadelphia Inquirer
Written by: Michael R. Cohen, Ph.D.

6/15/2015 – Several tragic deaths about 15 years ago were compelling factors that led to patient- and family-initiated “Rapid Response Teams” (RRT) that were mentioned in my June 3, 2015 blog.  The first was a tragic death of an 18-month-old child, Josie King, who had been hospitalized for treatment of burns from a bathtub accident. Josie had been healing well, but she died 2 days before she was supposed to go home. Hospital staff failed to recognize that Josie had become seriously dehydrated, despite frequent pleas by the child’s mother, Sorrel, that her daughter was listless and extremely thirsty—and that something was very wrong. The child’s mother was the first to notice her daughter’s desperate thirst. When the child saw a drink, she would scream for it. And when bathing, she would suck frantically on the wet washcloth. She then developed a fever and diarrhea—another cause of serious dehydration. When she became listless and her eyes rolled back in her head, Sorrel frantically tried to get help for her child because she felt something was not right. But in the end, the young toddler died of a third-world illness—dehydration—in one of the best hospitals in the world, despite repeated attempts by her mother to draw attention to the problem.

The other tragic death involved a previously healthy 15-year-old boy, Lewis Blackman, who went into the hospital for an elective surgery and died 4 days later from excessive blood loss caused by a serious side effect of his pain medicine. His mother, Helen Haskell, reported that her son was pale and was experiencing excruciating pain in his abdomen, which she thought was unusual given that the surgical site was his chest. Lewis developed a high fever, low blood pressure, very pale and cold skin, and many other signs of internal bleeding and clinical deterioration. The boy’s mother repeatedly insisted that her son be evaluated by a veteran doctor, rather than the new residents on duty over a weekend, because she knew something was very wrong with her son. But her repeated demands were never honored. Lewis died from internal bleeding caused by an ulcer, a known and serious side effect of the pain medicine, ketorolac, he was receiving.

Sorrel King and Helen Haskell have no doubt that access to a RRT could have saved their children, as the errors that caused their deaths were preventable and detectable. Likewise, we have no doubt that a patient- or family-activated RRT could have mitigated harm that has resulted from other life-threatening and deadly medication errors.

Allowing patients and families the ability to summon a RRT may be one of the most significant ways that healthcare providers can make patients an equal partner in their care and safety. To make the most of this opportunity, consider the following recommendations to best protect yourself and your family from accidental harm while hospitalized.

First, learn about the disease, medical tests, and the treatment plan for you or your hospitalized family member. Also learn what medicines are being administered, the prescribed doses, and when and how they are given. Write down important information. A patient or family member who knows what to expect can help recognize when something is not right.

Next, ask how to call an RRT. When admitted to a hospital, ask whether patients and families can call a RRT and under what conditions such a call would be appropriate. Be sure you and your family know how to summon for one. Report anything that worries you or does not seem right with you or your family member. Do not be afraid to speak up. Although doctors and nurses are highly trained regarding your medical condition, or your family member’s condition, you know yourself and your family better than anyone on the medical team. Your observations are extremely important.

If you have questions about your care or family member’s care, you need to ask. Also, if you do not understand the answer you get, you need to ask again. Keep asking questions or voicing your concerns about your condition or care, or your family member’s condition or care, until you get an answer that makes you comfortable. If you feel no one is addressing your concerns, do not hesitate to summon a RRT using the directions provided upon admission. If the hospital does not offer a RRT, ask to speak to the doctor in charge (medical director), nurse in charge (nursing director), and the patient representative.

Speak up about the care provided. If you believe something is not being done correctly—perhaps a medicine or medicine dose does not seem right—do not be afraid to speak up. Healthcare professionals are human; they could make a mistake. Sadly, patients, families, and healthcare providers often live with regret because they did not follow through on a suspected problem. The lessons they want to share with all is to speak up and be persistent, even if there is just a hint of a potential safety issue.

Click here to read the original article.

– See more at:

Read More

Upper Chesapeake Health’s Karmel earns Josie King Hero Award

Published in: Cecil Daily

6/3/2015 – BEL AIR — Lisa Karmel, director of guest services at University of Maryland Upper Chesapeake Health (UM UCH) received the Josie King Hero Award recently. The award founded by the Josie King Foundation and presented at a senior leadership team meeting, recognizes those who create a culture of patient safety.

The award has been presented four times nationally, and Karmel is the first member of the UM Upper Chesapeake Health team to receive it. It was presented by MaryBeth Foard-Nance, a patient-family advisor at UM UCH, who also nominated Karmel for the honor.

Karmel has been a member of the UM UCH team for 30-years. She has led the guest services team since 1999. In addition, she is a member of the hospital’s ethics committee and chairs the Patient and Family Centered Care Process Action Team. This group works with patients and their families to find mutually beneficial ways to coordinate patient care.

“We are very proud of Lisa Karmel. Patient safety and quality care are the cornerstones of our culture of excellence, and through her example and hard work, we are seeing great results for our patients, families and community,” said Lyle E. Sheldon, President and CEO at UM Upper Chesapeake Health.

The Josie King Foundation works to unite healthcare providers and consumers and funds innovative safety programs to create a culture of patient safety. The foundation was named in memory of Josie King, an 18-month old who died of medical errors in 2001. The Josie King Hero Award recognizes those who value patient safety by setting an example for others and inspiring positive change.

“I am so humbled to receive this award,” Karmel said, “and I am so lucky to have the position I do.”

In December 2013 Upper Chesapeake Health became University of Maryland Upper Chesapeake Health. It consists of the University of Maryland Upper Chesapeake Medical Center in Bel Air and the University of Maryland Harford Memorial Hospital in Havre de Grace. The leading health care system and largest private employer in Harford County, UM Upper Chesapeake Health offers a broad range of health services, technology and facilities to the residents of northeastern Maryland.

Click here to read the original article.

Read More

The healthier your hospital the better your outcomes

Published in: Not Running A Hospital
Written by: Paul Levy

4/29/2015 – I recently attended an Oslo meeting of the Dr Foster Global Comparators, an international group of hospitals that have been working together to share data and insights related to quality and safety.  What makes the group particularly interesting is their attempts to draw comparisons across national boundaries. This is no easy task, given the different manner (and for different purposes) in which countries collect administrative and clinical data; but the group has made good progress in several areas—notably GI, stroke, sepsis, and orthopaedics. At this session, I met committed and interesting folks from the UK, US, Denmark, Norway, China, Saudi Arabia, the Netherlands, and Australia.

While all the presentations were engaging, the one that most intrigued me was one offered by two surgical fellows from Imperial College, Christopher Nicolay and Stephen Williams. As I understand it, Christopher conducted much of the original research, and Stephen is now going to pick up on it and carry it forward. I’ll just present a quick outline here, as I’m confident they will formally present the results elsewhere, and I don’t want to steal their thunder.

The session was entitled, “The healthier your hospital the better your outcomes.” The hypothesis being tested was whether there might be a correlation between organizational health and clinical outcomes. The fellows first drew on the literature to help think about the elements of organizational health in hospitals. An initial definition by Chris Argyris (1958) set the stage: “A healthy organization is one that enables mature human functioning.” Then, a quote from Christin Shoaf et al (2004): “Organizational health blends the pursuit of individual wellness with organizational effectiveness to yield a strategy for economic resilience.”

Using interviews with many folks, a thoughtful model was derived for assessing organizational health for 22 acute care NHS trusts in the UK. Those assessments were then correlated with patient outcomes like mortality rates and critical incident reporting. Sure enough, there was a positive correlation.

While we’ll all look forward to the formal publication of these results, I can already predict two reactions to this kind of study. The naysayers will say that the concept of organizational health is just too fuzzy to quantify, much less correlate with measure of clinical outcomes (which, they will also say, are themselves too uncertain to use and rely upon.)

Others of us who have run hospitals, visited others, and studied others have seen that the quality of the work environment inevitably has an impact on patient outcomes. An organization in which staff wellbeing, effective communication, resilience, efficiency, and servant leadership are extant tends to be very good as a learning organization and tends to be more alert to the needs of its patients and more adept at clinical process improvement.

Stephen’s next step is to try to extend the research across national boundaries and investigate whether similar patterns might show up around the world. Congratulations to these two young men for taking on this topic and helping us gain deeper insights into the matter.

Click here to read the original article.


Read More

Running saved Sorrel King after 18-month-old daughter’s death

Published in: Boston Herald
Written by: Chris Mason


(Boston, MA - 4/19/15) Sorrel King of Baltimore is running the Boston Marathon for the Josie King Foundation, Sunday, April 19, 2015. Staff photo by Angela Rowlings.

(Boston, MA – 4/19/15) Sorrel King of Baltimore is running the Boston Marathon for the Josie King Foundation, Sunday, April 19, 2015. Staff photo by Angela Rowlings.

In the aftermath of the 2013 bombings, the Boston Marathon has become a place where runners congregate to cope with tragedy. Victims will take on the 26.2-mile course alongside countless others who use running as a tool to overcome a myriad of losses.

Sorrel King will be taking on Heartbreak Hill for the first time today. For King, running was crucial in overcoming the loss of her 18-month-old daughter, Josie.

“When my daughter died, running in some ways .?.?. saved my life,” King said. “And running has helped me throughout, just as it does for everyone who is a runner.”

In 2001, Josie King suffered second-degree burns that covered over half of her body following a water heater malfunction at the family’s Maryland home. She was admitted to Johns Hopkins Hospital, and suffered from severe dehydration. While there, she fell victim to oversedation. One morning it got to the point that her doctor ordered she no longer be given any more methadone.

Later in the day, a nurse came in with a syringe filled with the painkiller. The nurse assured Sorrel King that orders regarding her daughter had changed despite the doctor’s earlier recommendation, and that she was to administer the medication.

“I said to myself, ‘Do I run up to the nurse and knock the methadone out of her hand and scream for help?’?” King said. “Or do I say, ‘I’m at the best hospital in the country?’?”

The mother put her faith in the doctors, and shortly after the injection her child’s heart stopped beating. Josie King suffered severe brain damage, and ultimately Sorrel King and her husband had no choice but to take her off of life support.

Running was what Sorrel King turned to.

“For me, it’s how running got me out of a tragedy,” King said. “I think tragedy brings people together. Tragedy in some respects I’ve learned brings out the best in people. Running helped me deal with my tragedy. I think running helped me, and helps people deal with life. It really, really helped me deal with my tragedy. I think with what happened a couple years ago in Boston, that’s what makes this even more — for everyone, not just me, for everyone I think — more meaningful. It’s about tragedy and running.”

As a result of the medical error, King was awarded a settlement. She was reluctant to take it, but ultimately decided to form a foundation in her daughter’s memory.

“Hopkins gave us money,” King said. “For a long time we didn’t want to accept the money because we felt like accepting the money was letting them off the hook. Then our lawyer said take the money: Money is power. You can do something for Josie, and that’s exactly what we did. With some of the money from the settlement we created the Josie King Foundation.”

The foundation strives to curb medical errors and works with hospitals to streamline communication between doctors. According to King, 98,000 people die from preventable errors annually.

King is generally uncomfortable asking for money, but will be accepting donations for her foundation ( for the first time at the 119th running of Boston’s oldest race. It will be her fourth marathon in the last 18 months.

Today, King won’t be alone as she strides to overcome grief and anger.

“It had to be Boston for the foundation,” King said. “I want the people that I’m asking for money to know that I sacrificed myself for this.”

Click here to read the article on the Boston Herald.


Read More

Implementation of the Josie King Care Journal in a Pediatric Intensive Care Unit: A Quality Improvement Project

Published in: Journal of Nursing Care Quality
Issue/Volume: July/September 2013 – Volume 28 – Issue 3 – p 257-264
Written by: Turner, Kathleen DNP, RN; Frush, Karen MD; Hueckel, Rémi DNP, CPNP-AC; Relf, Michael V. PhD, RN, ACN

7/22/2013 – To read the full article: JNCQ article

For more information about this press release, please contact Kate Thorne at 410-504-1866 or via email at

Read More

The thoroughbreds were in MD, not KY


Issue/Volume: SUNDAY, MAY 05, 2013 Blog Post
Written by: Paul Levy


To read the full bolg post please visit Paul Levy’s “Not Running a Hospital” blog at:

SUNDAY, MAY 05, 2013

The thoroughbreds were in MD, not KY

As I headed to BWI airport early Friday morning, my seatmate turned and asked if I was staying on the flight to connect to Louisville, to watch the Kentucky Derby.  “No,” I replied, “I’m going to Maryland to watch the real thoroughbreds in action.”  A quizzical look was the response.

I was headed to a meeting of MedStar Health’s Patient and Family Advisory Council for Quality and Safety, convened by Dr. David Mayer, Vice President, Quality and Safety.  With strong suport from the system’s CEO and Board, David is leading a system-wide effort to make the Medstar hospitals the best in the nation for quality, safety, and transparency. 
Read More

Nursing: The most trusted profession in America

A caring career holds numerous opportunities for service

Published in:
Issue/Volume: May 2, 2013
Written by: By Cindy Atoji Keene



For more information about this press release, please contact Kate Thorne at 410-504-1866 or via email at

– See more at:

Read More