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.