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an online version of the magazine Spring/Summer 2004
Features
A Remedy of Errors Picture of stethoscope in waiting room
 
  Out of a deadly medical mistake at Hopkins Hospital sprang a patient-safety effort that has united a bereaved parent with malpractice lawyers, physicians and nurses.
BY MARY ANN AYD
 
 
 
 

In the early 1970s, when George Dover trained as a pediatric hematologist, he learned from the outset that tragic endings would be an inevitable part of his job. At that time, the prognosis for most of his patients—children with leukemia or sickle cell disease—was still grim. “I spent my formative years in medicine,” says the director of the Johns Hopkins Children’s Center, “talking with parents who were grieving or about to grieve.”

Yet on the windy March Sunday in 2001 when Dover met Tony and Sorrell King, even his three decades of insight seemed inadequate. What could he possibly say to this man and woman whose 18-month-old daughter had died at Hopkins just days earlier, not of some rare, incurable disease but of thirst? Josie King had not been Dover’s patient; he had never met her parents. But, having talked with those who had cared for Josie, Dover had no doubt that her death was indeed due to medical error. When he arrived that winter day at the Kings’ suburban Baltimore home, Dover knew he had a lot of listening to do. When he did speak, he said the one thing, perhaps the only thing, that mattered.

“We knew what had happened,” says Sorrell King. “We wanted someone to tell us why—why didn’t they listen to us when we said something was wrong with Josie, why didn’t they give her something to drink? We were involved with our lawyer then. We were going for it. If George had said, ‘We’re not sure what happened,’ we would have thrown him out. But he totally did the right thing, at least from our perspective. He said, ‘I am so sorry. This happened on my watch, at my hospital. I will help you get to the bottom of it.’”

To physicians who’ve seen their malpractice insurance premiums skyrocket in recent years, Dover’s promise could seem tantamount to handing the Kings’ attorney his case on a plate. Dover didn’t view it that way. Neither did those he consulted: Hopkins Medicine Dean and CEO Ed Miller, Hospital President Ron Peterson, Hospital Medical Affairs Vice President Beryl Rosenstein—even the Health System’s managing attorney for claims and litigation, Rick Kidwell.

“I had the full support of the administration,” says Dover. “Everyone encouraged me to be the line of communication.”

And at first, says Dover, what the Kings wanted most was to know who was at fault. “I saw their anger, their entirely appropriate shock. Their need to assign blame was completely understandable. But it was Sorrell’s desire to really understand how the events came together that has led to something none of us could have anticipated. She decided to help us become better.”

 

*****

 

In a profession that people enter because they want to heal, the potential to nevertheless do harm arrives with every patient. Misplace (or misread) a decimal in a prescription, reverse an X-ray or overlook a medication allergy and the outcome can be irreversible. It’s tempting, but simplistic, to attribute such errors to incompetence. In a 2000 British Medical Journal editorial called “Medical Error: The Second Victim,” Hopkins Associate Professor of Medicine Albert Wu wrote, “Virtually every practitioner knows the sickening realization of making a bad mistake.”

What surprised a lot of viewers of “Hopkins 24/7," the six-part ABC News documentary that aired during the summer of 2000, was the segment showing a morbidity and mortality conference. Even some veteran Hospital employees had no idea that physicians regularly meet to review serious complications and errors, or that these conclaves—dubbed M&Ms—have been considered an essential part of ongoing medical education, particularly among surgeons and anesthesiologists, since early in the 20th century. At Hopkins, M&Ms or their equivalent are held in every department.

That physicians cannot make 100-percent-correct treatment decisions 100 percent of the time has never been a secret—among physicians. The tightly closed doors of an M&M have offered a haven where a mistake can be dissected among colleagues in the best position to understand the events and offer solutions to prevent a similar incident.

But five years ago, the Institute of Medicine, the National Academy of Sciences’ think tank on health and science policy, blew a huge hole in the theory that examining an error after the fact is enough. Along with its headline-making statistic that as many as 98,000 fatal mistakes occur every year in the U.S. health care system, the IOM made plain that the natural human inclination to try to learn in private from your mistakes actually tends to keep the circle of responsibility—and truly effective prevention measures—too narrow.

For Ron Peterson, the report hit home on two levels. “It was a real reminder that what had happened to me was being repeated,” says the Hopkins Hospital president. “I personalize it time and time again because of the premature loss of my dad. He died in 1985 at a hospital in Florida as a result of a medical error.”

Rick Kidwell
> Health System attorney Rick Kidwell: “If Hopkins is clearly in error, we don’t contest liability.”
It was as the Hospital’s top executive, however, that Peterson understood the IOM report’s call to action. What had once been the prevailing belief in such industries as aviation—that a certain level of injury is inevitable—was then still largely being accepted in health care, he says. Hospitals and other care providers tended to see—and examine—each error as an isolated incident. The resulting rules, regulations and changes in practice, obviously aimed at keeping patients safe, made it seem that everything possible was already being done.

But, drawing lessons from how commercial aviation has slashed the number of plane crashes by encouraging employees to report safety problems without fear of incrimination or retaliation, the IOM pointed out that the fix doesn’t center on rooting out and punishing bad apples, or blaming everything on “pilot error.” Making headway, said the IOM, requires seeing the flaws in how the health care system itself is organized. Since to err is human, the answer lies in buttressing the systems people work in so the mistakes they’re bound to make don’t snowball into actual harm.

Just as Peterson and other Hopkins Medicine leaders were hammering out their plans to make patient safety the institution’s No. 1 priority, Josie King arrived at the Children’s Center intensive care unit with scald burns from a bathtub accident. Two weeks later, her injuries healing nicely and her recovery well under way, she was transferred to the intermediate care unit. Two days before she was due to be discharged, the little girl died of dehydration.

Despite the army of people involved in Josie’s care and the reams of records they kept during her three-week hospitalization, no one caught the signs that she was in danger until it was too late.

 

*****

 

The policy Rick Kidwell inherited when he joined the Hospital’s legal department 10 years ago is one he had no struggle agreeing with. “If Hopkins is clearly in error, we don’t contest liability,” says the attorney who’s in charge of handling all medical malpractice claims against the Hopkins Health System. “We apologize to the patient or family, take responsibility, explain what happened and tell them what we’re doing to prevent it from happening to someone else. My philosophy is, Do the right thing and don’t worry about legal fallout. We don’t say things just to make a claim go away.”

In such cases, Kidwell’s goal is twofold: to let patients know that Hopkins is committed to providing the safest possible care, and to reach an agreement on how to compensate them for their loss. From that point forward (and usually from the beginning), the discussions are nearly always with the family’s attorney.

But three years ago, almost immediately after Josie King died, even Kidwell was surprised when he learned that the child’s primary care pediatrician had called George Dover and said Josie’s parents had questions that, as head of the Children’s Center, he might be able to answer. Would Dover join her in a meeting at the Kings’ home?

“This was unusual,” says Kidwell. “We didn’t put the legal stuff first. George’s willingness to reach out to the family went far beyond what’s normally expected. He really stepped up.”

Initially, says Dover, Tony and Sorrell King were focused on details. After Josie had been moved from intensive to intermediate care, it was her mother who’d noticed the child’s thirst but was told not to let her daughter drink. Later, when Sorrell saw Josie’s eyes rolling back, she asked the nurse to summon a doctor. The nurse reassured Sorrell that Josie’s vital signs were fine. Sorrell asked that another nurse be called in; again, she was told not to worry. The following morning, Sorrell took one look at Josie and demanded a doctor. The medical team arrived, administered a pain reliever and at Sorrell’s request, okayed liquids by mouth. Josie guzzled nearly a liter of juice and gradually perked up. Early that afternoon, despite an order for no more narcotics, Josie was given an injection of methadone authorized by a different physician. Her heart stopped as Sorrell was rubbing her feet. A horde of physicians and nurses rushed in; Josie was whisked back to intensive care. But this time, the hospital that had come so close to healing her could not reverse the brain damage she sustained. She died on Feb. 22, 2001.

“The Kings lived through this hour by hour, if not minute by minute,” says Dover. “What they didn’t have was an understanding of how the events came together, how the different hospital services here relate to each other. It wasn’t one doctor, one nurse, one floor. I needed to own up to the system’s part.”

After his first visit with her, Dover promised to call Sorrell every Friday morning. The Kings wanted to testify before the Hospital review committee that was examining Josie’s death, and Dover helped set that up. He also agreed to meet with Josie’s grandparents, who he says were not only grieving her death but were concerned about how it was affecting Josie’s parents, their own children, as well.

Some weeks when Dover called Sorrell he could say little more than that he had nothing to report. Sometimes, he just listened.

“I would say, How are you gonna fix this, George? I wasn’t asking, I was demanding,” remembers Sorrell. “I would threaten him; I would say horrible things. There were many times I would say, We’re gonna pull out big guns if we have to. I wanted to call the newspapers; I wanted to strangle Hopkins. From the very beginning, I needed to do something huge.”

George Dover
> “The usual way the wheels turn around here is to see a problem and collect lots of data. Change can take years.” — George Dover

Even in her darkest moments, however, Sorrell recognized that no one had intended to hurt her daughter. Furthermore, Hopkins was listening. “My husband, our lawyer and George were holding me back from going to the newspapers,” says Sorrell. “Tony really saw that it would be a story—a headline—and then what? At some point, someone said to us, Anger can do two things: It will make you rot away and expect pity forever and ever, or you can take the energy from your anger and let it propel you forward.”

It wasn’t until after the Kings’ attorney had wrapped up their monetary settlement in August 2001 that Sorrell decided to call Rick Kidwell. “What happened to Josie—was that a strike of lightning?” she asked. “Was that some rare occurrence?”

The honesty of his answer astounded her. “No,” Kidwell replied. “It’s not rare. It happens at every hospital.”

“He opened my eyes that we weren’t the only ones,” says Sorrell. “Then he said, You can’t just walk away from this. You can change things.”

Peter Pronovost helped Sorrell see how.

An associate professor of anesthesiology and critical care medicine, Pronovost was the first person the Kings met who understood what they were going through—from both sides of the aisle. He had been a fourth-year medical student at Hopkins when his father died as a result of an error made by a hospital in New England. And as a physician, he trained and worked in a system that he says invests far more in discovering therapies than in making sure they’re effectively delivered to patients.

By the time he joined the Hopkins faculty in 1999, Pronovost was well on his way to becoming a national expert in ways to mend the system breakdowns that foster mistakes. Furthermore, the cultural change he envisioned—in which front-line caregivers are not only encouraged to think about how things can go wrong but get the tools they need to help them go right—was something both Hopkins leaders and Tony and Sorrell King could embrace.

 

*****

 

At hospitals coast to coast, finding new ways to talk about medical errors has become an imperative, not only to spread the lessons beyond local morbidity and mortality conferences and hospital review committees but to change a culture of secrecy and blame that does little to prevent mistakes in the first place. Physicians, nurses and the myriad others who contribute to patient care have been historically reluctant to speak openly. “We’re trained from our earliest days in school that health professionals don’t make mistakes, and if you do, you don’t talk about it,” says Beryl Rosenstein, Hopkins Hospital vice president for medical affairs.

Furthermore, the schools themselves neither teach courses in error prevention nor offer training in the teamwork that’s so necessary when members of varied disciplines must collaborate in a fast-paced, high-tech, risk-laden environment. Add to this mix the traditional hierarchy of an academic medical center—where nurses may hesitate to raise concerns with doctors, residents may feel uncomfortable about second-guessing attending physicians, and everyone may overlook the concerns of patients and families—and it’s no wonder that faulty communication has been cited as a culprit in nearly 85 percent of medical errors.

“In almost all cases,” says patient safety expert Peter Pronovost, “someone sensed something was wrong but didn’t speak up.”

By September 2002, Sorrell King had mustered the strength to tell her story—not to the media, but to a standing-room-only throng of Hopkins Medicine leaders and staff who’d gathered in the Hospital’s oldest auditorium. She and Tony had decided to donate a portion of their settlement back to Hopkins to fund the Josie King Patient Safety Program.

“Josie’s death,” Sorrell told the crowd in Hurd Hall, “was the result of a combination of many errors, all of which were avoidable. You are the only ones who can solve this problem. The medical community must be open to the possibility that shortcomings do exist, and you must be prepared to make the necessary changes.”

There’s little question that the Kings’ resolve to become partners with Hopkins gave a new sense of urgency to ideas for safety improvement that were already in the works. “That was one of the most important catalysts to move us forward,” says Rosenstein.

Today, as part of a program called Executive Safety Rounds, each of the institution’s corporate officers has adopted an intensive care unit, become its advocate, and at monthly meetings with its staff members, encouraged them to openly discuss safety issues affecting their patients.

With funding provided by the University, Hospital and School of Medicine, Hopkins has established the Center for Innovation in Quality Patient Care, a learning laboratory that teaches front-line care providers how to troubleshoot and helps them get the resources to do it.

On many units, the use of checklists, such as pilots use before take-off, has slashed the incidence of catheter-related bloodstream infections by more than 50 percent. The checklist concept also has been used in the Hospital’s intensive care units to improve patient care rounds. Now, instead of focusing primarily on teaching medical students, residents and fellows, the bedside visits also include a daily goals sheet that prompts the entire care team to identify each patient’s greatest safety risk and what they need to do to get the patient to the next level of care.

And to help reduce medication errors, the first phase of a $20 million computerized system rolls out this spring in the Department of Medicine. It will allow physicians to order medications and other interventions for their patients without having to physically write their instructions. Every few months, more units will be added to the system until the entire hospital is covered.

But most importantly, the massive, top-down push for safer patient care is taking hold in ways that few Hopkins veterans would have believed possible even three years ago.

“The usual way the wheels turn around here,” says George Dover, “is to see a problem and collect lots of data. Change can take years. But how far we’ve come at the Children’s Center was driven home to me when I saw the Josie King safety teams being formed and all these people thinking about what we can do better.”

In December 2002, the Children’s Center held its first patient safety summit. Staff revealed medical situations they’d identified as being most vulnerable to error and shared solutions. Among the changes they’d implemented were improved communication between respiratory therapists and pediatric nurses, stepped-up training for residents in calculating and documenting pediatric medication orders, and the replacement of bottles of dangerous, undiluted heparin with pre-mixed bags of the anticoagulant in the neonatal intensive care unit.

“All these teams came together in Hurd Hall—that very formal room that’s such a perfect example of the academic medical hierarchy—to teach each other what they’re doing to change things at Hopkins,” says Dover. “Sharing the teaching podium were a front-line nurse, a pharmacist, the chief of pediatric trauma surgery, a resident, a fellow, a neonatologist. And sitting behind me, in the audience, were Ed Miller, Ron Peterson and most of the executive leadership of the Hospital and the School of Medicine.

“I sat in the front row and thought, Look who’s teaching whom.

“This hasn’t happened here before.”

 
 
 
 
Features
 A Remedy of Errors
 Childhood Trials
 Meat Muddle
 
Departments
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
 
Opinions
 Learning Curve
 Post-Op
 
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