‘It is almost magic in their eyes’

‘It is almost magic in their eyes’ photoQ&A with doctor who created infection-prevention checklist

Issue/Volume: Posted: 3:46 p.m. Saturday, April 27, 2013

4/27/2013Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine, has become well-known at hospitals nationwide for developing a proven method of reducing deadly infections associated with central lines. His checklist and changes to hospital culture led to astounding decreases in these infections in a landmark study conducted in Michigan. The protocol is now being used across the U.S. He recently spoke with the AJC’s Carrie Teegardin by phone. This is an edited transcript of his remarks.

Q. What first made you challenge the conventional wisdom that most hospital infections were not preventable?

A. What really made it happen was a little girl, Josie King, died in my hospital at 18 months of a catheter infection, and she looked hauntingly like my daughter. She died on my birthday. Her mother, an amazing woman, Sorrel King, was working with the hospital, and she came to me [months later] and looked me in the eye and said, “Could you tell me my daughter would be less likely to die now than a year ago?” In many senses, I made excuses: “Well, I’m doing this, I’m doing that.” And she cut me off and said, “Peter, I don’t care what you’re doing. That’s your job. Just get your infection rates down.” It was really an epiphany for me, truly like a Paul on the Road to Damascus. And I said, “Sorrel, I can’t give you an answer, but you deserve one and I will.” And that’s what really drove it. I started looking at Hopkins’ rates and our rates were sky high and it was really humbling and I said, “I don’t want to be killing little girls.”

Q. Tell us more about how your program changed the culture in hospitals?

A. We changed the social norms from “these infections are inevitable,” which was the common mental model. It was my own mental model when I started as a doc and I was causing these infections. It changed to say, “Not only are they preventable, but I am empowered to do something about it.” Many clinicians are completely disempowered and they feel like they are a cog in the wheel and say, “I’m just a nurse or a doc. Who am I to think I can change it?” What we have seen is, it is almost magic in their eyes when that switch goes off and they say, “I get it. I could actually do this.” It’s that belief system that either holds them back or launches dramatic improvements.

Q. What’s the strongest motivator to get hospitals to improve?

A. The federal government’s main approach to improving quality has been pay for performance, in other words an economic model, [and] there is essentially no data that it works. What I call extrinsic motivations — either pay for performance or public reporting [the practice in many states of requiring hospitals to provide a public accounting of their infection rates] — haven’t really realized improvements. The project we led was all intrinsic motivations. That is not to say pay for performance and public reporting don’t have a role but I think it has to supplement, not supplant, intrinsic motivations. If you have the tribe believing this is a big problem and we can solve it, then pay for performance or public reporting is like gasoline on it. It will accelerate it. If the tribe doesn’t believe they can solve it, if you haven’t garnered that intrinsic motivation, you can do all the pay for performance you want and that won’t translate into measurable improvements.

Q. What’s the most important factor in improving patient safety?

A. There’s a famous physician who was kind of the father of quality improvement, and when he was on his deathbed he was interviewed. “OK, what’s the secret of quality now that you have devoted your life to it and you have been a patient?” He said the secret of quality is love: if you have love you change the system. It may sound corny but it’s true — love your patients, love your colleagues, love your profession. The magic is not in the checklist.


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Vail Valley Medical Center celebrates patient safety

Vail Valley Medical Center has announced its participation in the 2013 Patient Safety Awareness Week campaign, Patient Safety 7/365 and will offer a free luncheon event called “Josie’s Story – A Family-Centered Approach to Patient Safety.”..

Published in: Vail Daily
Issue/Volume: 4/26/13
Written by: Daily staff report


Vail Valley Medical Center celebrates patient safety
Luncheon event scheduled for April 3
 If you go …
“Josie’s Story — A Family-Centered Approach to Patient Safety”
• Guest speaker Sorrel King.
• Presented by VVMC & Kimberly Linn McDonald Foundation.
• April 3, 12-2 p.m. at The Sonnenalp in Vail.
• Free and open to the public.
• Lunch provided.
• R.S.V.P. to vvmcdevelopment@vvmc.com or 970-477-5177.

VAIL, Colorado — In an effort to raise awareness and encourage the engagement of patients, families, health care providers and the community, Vail Valley Medical Center has announced its participation in the 2013 Patient Safety Awareness Week campaign, Patient Safety 7/365 and will offer a free luncheon event called “Josie’s Story – A Family-Centered Approach to Patient Safety.”

The event, which is part of the Friends of VVMC speaker series, will be held on April 3 from noon-2 p.m. at the Sonnenalp in Vail. Guest speaker Sorrel King authored “Josie’s Story: A Mother’s Inspiring Crusade to Make Medical Care Safe” after losing her daughter as a result of a medical error in 2001. King was also chosen as one of “50 Women Changing the World” by Woman’s Day magazine.

Consumed by grief, King was determined to honor Josie’s memory. King has become a nationally renowned patient safety advocate and travels the country spreading her message to inspire change and create a better, safer healthcare industry.

Patient Safety Awareness Week is an annual education and awareness campaign for health care safety led by the National Patient Safety Foundation. Patient Safety Awareness Week is March 3-9. This year’s theme, “Patient Safety 7/365,” highlights the need for everyone to understand the importance of focusing on patient safety all year round. The seven days of the campaign also serve as time to recognize the range of work being done to improve health care safety worldwide.

“’Patient Safety’ 7/365 reminds us that providing safe patient care requires a constant and valiant effort, 365 days a year. This week encourages a sustainable and conscientious collaboration between health care organizations, providers and consumers, regardless of their current state of health,” said Patricia A. McGaffigan, RN, MS, interim president, National Patient Safety Foundation.

For additional information on Patient Safety Awareness Week, visit www.npsf.org.

Vail Valley Medical Center is a nonprofit community hospital, serving the Vail Valley and its visitors since 1965.


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

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National Patient Safety Expert Urges Prevention of Medical Errors

Published in: University of Arkansas Medical Sciences Website


National Patient Safety Expert Urges Prevention of Medical Errors

Sorrel King shows an audience at UAMS one of the care journals distributed by the Josie King Foundation. 

While at UAMS, King also spoke to nurses about patient safety.

March 5, 2013 | A communications breakdown at Johns Hopkins Hospital killed 18-month-old Josie King just a day after she was declared healthy enough to go home after successful treatment for first- and second-degree burns.

Sorrel King, her mother, spoke March 4 at the University of Arkansas for Medical Sciences (UAMS) about how her daughter died from dehydration and misused narcotics. Now a national advocate for patient safety, King talked about how to address the problems that led to Josie’s unnecessary death in 2001.

“The thing with Josie’s death, like so many deaths due to medical errors, is that she did not die from a doctor’s mistake. She did not die from a nurse’s mistake. She died from a breakdown in communications,” King said.

Josie had been admitted to Johns Hopkins Hospital in Baltimore with first- and second-degree burns after climbing into a bath of scalding hot water. King noticed her daughter appeared thirsty, but she had been told not to let her drink. Two days before her expected release from the hospital and after receiving a final dose of methadone meant to help her cope with the pain of the burns, Josie’s health collapsed. She had been receiving the drug for pain, but her physician had ordered a stop to the medication. A second physician changed the order.

There were several points in Josie’s care at which things might have turned out for the better if only she, a doctor, a nurse or anyone involved had addressed the symptoms her daughter was showing, King said.

After Josie’s death, King and her husband resolved to do something. They used the money from a settlement of their legal case against Johns Hopkins to establish the Josie King Foundation. The foundation’s mission is to prevent others from being harmed by medical errors.

To get her message out, the foundation produced a DVD about her family’s experience, and King wrote a book, “Josie’s Story,” and continues to speak to health care professionals across the country about what happened to her daughter. The Josie King Foundation also created and distributes to hospitals copies of patient journals and nurse journals for use in chronicling their care and writing down questions and answers.

Earlier in the day, King visited with dozens of nursing leaders from the UAMS hospital and clinics. King shared her story and asked participants about the patient safety challenges they face. She encouraged the group to help others trust their instincts when they sense something’s wrong with a patient and not to merely rely on what the computer monitor says about their vital signs. She also talked about the importance of every member of the health care team feeling empowered and the need for improved communication when a patient’s care is handed off from one health care professional to another.

King also spoke about commitment to safety at a breakfast session with 14 UAMS Patient Safety Champions selected by their departments. Each honoree received an autographed copy of “Josie’s Story” and had an opportunity to discuss their patient safety practices with King and campus leaders.

King’s visit to UAMS was part of Patient Safety Awareness Week from March 3-9.

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


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Women Who Are Changing the World

Published in: Woman’s Day
Issue/Volume: December 2009
Written by: WomansDay.com Staff

12/11/2009 – Read Sorrel’s story and see the complete list at http://tinyurl.com/yc6x9jn.


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As Easy as 1-2-3?

Checklists can reduce infections dramatically. The trick is getting doctors and nurses to use them.

Published in: Wall Street Journal
Issue/Volume: October 27, 2009
Written by: Jacob Goldstein

10/27/2009 – Read the full article at http://tinyurl.com/yj7rjyq.
(Accessed on October 27, 2009)

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