Making The Rounds – University of Iowa 6th Annual Quality and Safety Symposium

6th Annual Quality and Safety Symposium, 11/15/18

DSC_0293“Facts provide us with knowledge. Stories provide us with wisdom.” Sorrel King, mother of Josie and founder of the Josie King Foundation, shared her story with the attendees of the 6th Annual Quality and Safety Symposium. The presentation began with the gripping story of the medical error that resulted in the death of her young child, Josie. But over the course of the hour, Ms. King revealed the work and improvements in patient safety throughout the healthcare system that her family’s loss continues to inspire.

Ms. King described a number of initiatives that the Josie King Foundation has supported in partnership with institutions around the country. Patient-initiated rapid response teams to “stop the line,” patient care journals in which families can keep track of daily goals and questions they have for their care team, and “hero awards” meant to recognize those individuals who speak up when something does not look right. “Just the existence of these programs,” Ms. King explained, even if they don’t get used all the time, “can change the culture.”

Though certainly Ms. King’s story was the most dramatic of the day, the entire symposium—the sixth since Krista Johnson, MD, MME, and Michael Brownlee, PharmD, MS, first began co-chairing the event—was a day filled with stories. About 35 different speakers packed Medical Alumni Auditorium and small breakout conference rooms around the hospital and the Carver College of Medicine. All of them presented on activities they have initiated or on systems and support available within University of Iowa Health Care designed to improve the quality of care patients receive and to ensure their and their providers’ safety.

Ms. King’s keynote challenged the audience to make changes that will benefit the system and save patients’ lives. But, she cautioned, most calls to action fade in effectiveness within three weeks. “If nothing happens by week three,” she said, “nothing will happen.”

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A Caregiver’s Journal: Helping Family Supercharge Caregiving

On the heels of National Family Caregivers Month in November, which this year carried the theme of “Supercharge Your Caregiving,” here is a way to carry out that charge year-round. And carry it out we must, because health care can no longer ignore these folks. The Caregiver Action Network estimates that there are over 90 million Americans doing this critical work, which is largely publicly invisible, unpaid, and underappreciated.

The Josie King Foundation recognizes those giant numbers and the outsize importance of the role that family caregivers play in the life of patients. The response to requests from non-nursing staff and family members, they now offer the Caregiver’s Journal, a variation of their signature Nurse’s Journal. Their aim is to provide a low-cost tool that can help alleviate some of the emotional stress of serving patients and loved ones with sensitivity, commitment, and compassion.

The journal was created with the help of experts in therapeutic expressive writing and road-tested in several facilitated writing workshops for caregivers. Here’s what participants had to say about their experience:

“I felt stressed at the beginning of writing and relaxed at the end.”

“I felt purged and able to breathe after writing in my journal.”

“I feel like I understand things better after I write them down.”

The Caregiver’s Journal is a 61-page spiral bound notebook filled with helpful content, such as psychological theories about journaling benefits, before and after stress evaluation forms, and suggested resources for those who want to learn more about expressive writing.

The majority of pages are meant to be used for writing sessions, and offer an inspirational quote with perhaps a guided writing prompt. For instance, one is titled guided writing page is titled When Times Are Difficult, with this prompt:

“Things to consider. What are the current situations causing you stress in our work or in your personal life? How can you alleviate these stressors? What steps have you thought about to make this situation better?”

The page ends with a quote from abolitionist Frederick Douglass, “If there is no struggle, there is no progress.”

Some “free writing” pages are empty except for a short quote, with this instruction about how to use them: The following pages are for you to write about anything that you want. Remember to go deep and really explore your thoughts and emotions. Avoid getting caught up on grammar or spelling. Just write.

Many hospitals buy these journals in bulk as a gift for caregivers or to use in staff training and development programs. For more information about the Josie King Foundation and their specialty journals for caregivers, visit

Jebra Turner is a freelance health writer in Portland, Oregon. Visit her online at for more self-care inspiration.

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A Nurse’s Journal: Writing Out the Storm

The Josie King Foundation believes that nurses are leading the charge for a safer, more compassionate health care system. But they realize that in addition to the joys of healing, nurses face many emotional upheavals related to patient suffering, a complex workplace, new technologies, and fear of clinical errors. When personal pressures from everyday living are added to the already heavy load, the weight can lead to nurse stress, anxiety, depression, or burnout.

The Josie King Foundation developed the Nurse’s Journal in 2004, to help alleviate stress through expressive writing. (The journal was a response to results from a research project, Care for the Caregiver, that indicated it was sorely needed.) Created with the help of experts on the topic and specifically for nurses, it is offered by the nonprofit as a tool for self-directed writing or through facilitated journaling workshops.

The Nurse’s Journal is an attractive 61-page spiral bound notebook and is filled with helpful content such as evidence-based theories about journaling, before and after stress evaluation forms, and suggested resources to help nurses cope with work-related stress.

The majority of pages are low-content, with just short guided writing exercises to help you reflect on the stresses of your work life and personal life. For instance, the first one is titled “Guided Writing: Signs of Stress,” and includes the following prompt:

“Things to consider. Do you notice stress-related symptoms in your life? Is there a particular time of day or day of the week in which you feel more stress? Do your stress symptoms affect your job performance or your quality of life? What do you do to combat your stress?”

The page ends with a quote from the Dalai Lama about avoiding the burnout associated with witnessing great suffering.

In between the prompt and the quote, the page is empty so that a nurse is free to write out their own personal thoughts and feelings, as an antidote to workplace and life stressors.

Since launching the Nurse’s Journal in 2004, the Josie King Foundation has distributed them to more than 15,000 nurses. Many hospitals buy the journals in bulk as a gift for nurses during the winter holidays, or to mark Nurses Week, or at anytime for staff training and development purposes. In addition, they offer a companion Nurse’s Journal Guidebook for anyone who would like to facilitate journaling workshops for nurses.

For more information about the mission of the Josie King Foundation and their line of specialty journals for nurses, caregivers, and patients, visit

Creative Nursing
A Journal of Values, Issues, Experience, and Collaboration
Today’s health care institutions need creative and innovative solutions. Nurses need to think creatively, to experiment, to take risks, and to innovate. Creative Nursing is an issue-focused journal that promotes best practices in all aspects of caring—caring for self, patients, families, colleagues, and communities.

Jebra Turner is a freelance health writer in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at for self-care inspiration.

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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:

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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.

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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.


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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

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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. 
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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 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

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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