In January 2001, Josie King, age one and a half, climbed into a hot bath and burned herself, but that wasn’t what killed her. She made a marvelous recovery at the prestigious Johns Hopkins Children’s Center in Baltimore, Maryland, USA, and after ten days in the pediatric intensive care unit she was well enough to move to the intermediate-care floor. It was there that a series of catastrophic medical mistakes — what her mother would later call "a combination of many errors, all of which were avoidable" — ended her life.

The first sign of trouble was Josie’s desperate thirst (dehydration, it was discovered later, from a preventable catheter infection). Her mother was told not to let her drink, but when she sucked at washcloths, the staff in charge of her care did not recognize the dehydration. Then her eyes rolled back in her head, and staff members assured her mother that Josie’s vital signs were fine and children just sometimes do that. And then there was the dose of methadone, which Josie’s mother questioned as there had been a previous order for no narcotics. It was administered by a veteran nurse who said the no-narcotics order had been changed. The methadone caused Josie to have a cardiac arrest, while her mother was at her bedside. Josie King returned to the intensive care unit, where she died of dehydration and misused narcotics.

By now it is sad common knowledge in the health care improvement field that Josie’s case is not unusual. Medical errors are among the four leading causes of death in the United States, killing as many as 98,000 Americans a year. What is unusual is the King family’s response. In October 2002, Sorrel and Tony King, Josie’s parents, launched the Josie King Patient Safety Program at the Johns Hopkins Children’s Center.

"On top of our overwhelming sorrow and intense grief, we were consumed by anger," Sorrel King told the Institute for Healthcare Improvement’s Patient Safety Collaborative in Boston, Massachusetts. "They say anger can do one of two things: it can cause you to rot away, or it can propel you forward. Tony and I decided that we had to let the anger move us forward. We would do something good that would prevent this from ever happening to a child again. It seemed like the best place to start was Johns Hopkins."

The Kings have been in close contact with the staff at Johns Hopkins; Sorrel King even spoke at a pediatric grand rounds. "It was magical," says Peter Pronovost, MD, PhD, an associate professor at the Johns Hopkins University School of Medicine and co-chair of the Johns Hopkins Hospital Patient Safety Committee. "The chairman of pediatrics invited the families of other patients who were harmed, as well as all staff, including senior executives, physicians, nurses, pharmacists, and housekeepers. All sat attentive as Sorrel spoke."

Under the Josie King Safety program, staff members at the Children’s Center have time dedicated specifically to examining their systems for safety problems. Representatives from medicine, pharmacy, and nursing lead multidisciplinary safety teams that draw from respiratory therapy, infection control, and other departments. "What happened to Josie is completely unacceptable," says Pronovost. "In the case of medical errors, only fixing the underlying systems that led to accident will get to the root of the problem." Sorrel King is a guiding team member.

The teams study the scientific literature of safety and error reduction and apply what they learn to devising practical systems changes. The Josie King Patient Safety Program is in its infancy, but work is beginning on improving multidisciplinary teamwork and medication safety, and plans are in place to import to the Children’s Center an eight-part safety initiative that showed tremendous success in intensive care units elsewhere in the hospital. The initiative’s improvements include dedicated patient transport teams, pharmacists in ICUs, medication reconciliation at the moment of nursing discharge, daily short-term goal sheets for patient rounds, and relabeling of Buretrol and epidural catheters.

Currently the doctors, nurses, and pharmacists on the teams dedicate about 20 percent of their time to the cause; Johns Hopkins is working to secure endowments to protect and expand that time. Part of that funding will probably come from the Josie King Foundation, which has been partially funded by the Kings themselves, along with Johns Hopkins. The Foundation was created by the King family to support Johns Hopkins’s pediatric safety programs and, eventually, safety efforts elsewhere in the hospital and in other institutions.

"This problem is unlike cancer, AIDS, or other diseases, where we must wait for a scientific breakthrough in order to save lives," Sorrel King told the audience in Boston. "Hospital errors are a man-made epidemic. Nurses and doctors make mistakes, and lives are being lost. These human errors need a human solution."