Published: November 23, 2009 10:37 pm         

When time is precious, ‘family activated rapid response teams’ can help save lives

TERRE HAUTE — “I think she’s thirsty,” Sorrel King told a nurse at Johns Hopkins Children’s Center in Baltimore.

King was speaking of her 18-month-old daughter, Josie, who was recovering from an accident that occurred two weeks earlier. The young girl had recovered nicely and was expected to go home in a couple of days.

But Josie wasn’t given a drink because the day before she had vomited after drinking. A doctor ordered she only be given crushed ice that day.

Later that day, King was able to hold her daughter for the first time in two weeks and she and a nurse gave Josie a bath.

During the bath, Josie was “sucking furiously on a [wet] wash cloth,” but still no drink was provided.

“I think something’s wrong with Josie,” King told a nurse after the bath. Josie’s coloring was “off” and her eyes appeared sunken, King said.

“Her vital signs are fine,” a nurse told the worried mother.

Another nurse was requested and the same answer came: “Her vitals are fine.”

King, despite staying at the hospital with her daughter nearly round-the-clock since the accident, said she had tried hard not to be a troublesome mother for the hospital staff and doctors. But now she requested a doctor.

“I know she needs a drink,” King said. A doctor allowed Josie to have a drink and the 18-month-old girl finished nearly a liter of Gatorade. The doctor also gave a verbal order to the nursing staff to stop giving Josie methadone, a pain medicine. Josie’s condition started to improve, King said.

Then, at 1 p.m., a nurse came into Josie’s room with a dose of methadone for the young patient.

Sorrel King had to make a decision. She could complain and tell the nurse not to give the medication. Or trust the nurse, who said the doctor’s orders had been changed.

“They know what’s best for Josie,” King told herself. “So I stood aside.”

Within a few moments of receiving the medication, for the first time since entering the hospital, Josie shed a tear. Soon, she passed out. Within a day, she was pronounced “brain dead.”

“In 24 hours we went from planning a welcome-home party to planning a funeral,” King said.

Sorrel King, whose daughter Josie died from a medical error in 2001, is now working hard to prevent medical errors. She has written a book, “Josie’s Story,” started a foundation and taken her story to countless health care professionals around the country. At the invitation of Terre Haute Regional Hospital, King told her tragic story in Terre Haute on Monday, giving a 45-minute talk to nursing and medical students, hospital staff and educators at Indiana State University.

“I think Sorrel says it all so well,” said Chris Hill, CEO of Regional Hospital. The goal of bringing King to Terre Haute was to allow her story to reach Wabash Valley medical professional and students, Hill said. “It’s a compelling story.”

Several nursing students at the talk said King’s story made a strong impact on them.

“What a difference it will make to take five minutes” extra with a patient, said Crystal Haggart, an Ivy Tech nursing student at the talk. “That could save somebody’s life.”

Medical mistakes cause about 98,000 deaths in America each year, King said. That’s the equivalent of a jumbo jet crashing each day. In 1999, the Institute of Medicine, a federally funded organization, released a report stating that between 44,000 and 98,000 people die in hospitals each year from medical errors.

King’s “message is germane to everyone in health care,” said Carolyn Hamilton, chief nursing officer at Regional Hospital. Providing health care is complex, she said. Nurses and doctors should not only look at medical charts and hospital room monitors. They should also “look at the patient,” she said.

Among other things, King supports the formation of “family activated rapid response teams” at hospitals. These are medical teams that families can call if they suspect something is seriously wrong with the treatment a loved one is receiving. If Johns Hopkins had had such a team, Josie would be alive today, King said.

Using family activated rapid response teams, introduced at Regional Hospital last spring, has reduced the number of life-threatening emergency alerts at the hospital, said Rachel Massey, a registered nurse and patient director at the southside hospital. “The rapid response team has really reduced those substantially,” she said.

King, who launched the Josie King Foundation to further the cause of preventing medical errors, also urges patients and their families to write down questions for doctors and nurses.

“You need to be able to read your patients,” said Shannon Christopher, a licensed practical nurse and a nursing student at ISU. Nurses are really patient advocates, she said.

“The [patient’s] family knows that patient better than you do,” noted Jordan Sisson, a nursing student and an employee of Union Hospital. Sisson said she likes the idea of patients or their families writing down questions for medical professionals.

The nurses and staff at Johns Hopkins were “wonderful, wonderful people,” King said. No one intended to hurt her daughter. “She died from a breakdown in communication. … It was a culture thing. It was a communication thing.”

Visit www.josieking.org for more information on the Josie King Foundation.