“To err is human…”

To forgive is divine, especially when you’ve lost your child to senseless mistakes

Imagine you’re the mother of a beautiful 18-month-old girl. You entrust her to the care of a world renowned hospital and assume she is in good hands. Her wounds heal, and you think she is soon to be home. Instead, she dies two days later from completely preventable mistakes.

This is the story of Josie King. Josie entered John Hopkins hospital with severe first and second degree burns from crawling into a hot bath, but was recovering nicely.

After Josie’s central line was taken out, she began to show severe signs of thirst, like screaming whenever she saw something to drink and sucking very hard on a washcloth when receiving a bath. Her mother knew things weren’t right, but staff dismissed her concerns and Josie’s orders were that she was not allowed to drink. Then, Josie was overdosed on narcotics, but was given a reversal agent and pulled through. The doctor gave verbal orders to discontinue narcotics, and she was finally allowed something to drink. After these changes were made, her condition began to improve.

Later, a nurse administered a narcotic despite the mother’s concern, saying that orders had been changed. Josie’s heart stopped and she died two days later from dehydration and narcotic overdose.

If that verbal order to stop narcotics would have been transcribed to the computer or charts, things would have been different. If the nurse would have taken Josie’s mom seriously, or the doctors and nurses together would have looked at Josie’s clinical picture and her deteriorating state instead of just blindly sticking to their orders, she’d still be alive.

My very first semester of clinical, I was doing a pull-out to the emergency department with a wonderful nurse who had worked there for 40 years. We went to pull out an antibiotic and brought it to the patient’s room. I hesitated, however, wondering if that antibiotic was for the right patient. I swore it was for one of her other patients, but didn’t say anything because she was so experienced.

Luckily, just as soon as she hung it, she caught the mistake and switched rooms. However, if she hadn’t and I hadn’t spoken up, what could have happened? What if she had a terrible anaphylactic reaction to it?

Last semester, I decided to speak up on something. My patient was normally on Coumadin, a blood thinner, and was to be off it so he could have a much needed surgery. His Prothrombin time (a measure of how long his blood takes to clot; the longer the PT the longer the blood takes to clot) was still high, and his morning medications included another drug with blood thinning action.

While administering medications, I spoke up to my nurse and proposed to her if we should clarify with the doctor to have the blood thinner held. We did so, and sure enough, the physician agreed it should not be given. Because I spoke up, I reduced my patient’s risk of bleeding, and ensured he could get his surgery that much sooner. Doctors, nurses, and other health professionals are smart people, but they are not immune to error.

The first moral of the story is that medical malpractice is not an individual problem; it is a system’s problem. There needs to be safeguards in the system that prevent these collapses that lead to tragedies such as this, and healthcare staff need to work together, watching each other’s backs and being free to question each other when discrepancies are suspected. Parents need to have this freedom as well.

The second moral of the story is Josie’s story doesn’t apply to just healthcare for all you non-healthcare Ferris students out there.

The take-home lesson for all is this: Don’t assume. Don’t be afraid to admit you are wrong and to double check things, no matter how much experience you or the person you are questioning has. It could save time, face, money or a life. n