Please respond to these discussion posts:
The major factors that may have contributed to Josie King’s death is first lack of communication, meaning not taking the patient’s mom concern about what she deemed as abnormal from Josie baseline/normal behavior seriously. As well as ignoring the mother informing the nurse of the change in orders made earlier by the physician. Secondly, medical errors by way of not double checking the EMR before administering any medications but especially before administering narcotics.
Had the staff listened to the mother’s assessment of Josie’s normal baseline concerns with an unbiased opinion there could have been interventions implemented early enough to have saved her life. Allowing Josie’s mother to be the advocate for her child’s care was her right but it was stripped from her because the nurse administering her narcotic medication was not favorable about being questioned about her actions. What I would recommend is to listen to every patient individually. No two patients are the same nor are their individual experiences. Certain specialties can be copy and paste after an extended period of practice (i.e the ER, ICU, oncology) but you have to resist the notion of everything, and everyone is the same because of familiarity. Also continue to educate staff on the importance of understanding they are not above the patient/family members and can at any time questioned or can refuse treatment. This is a real problem in the culture of healthcare is a lot of staff feel superior and offended by questioning from patients to what they deem as their area of expertise. We have to change that mentality immediately to ensure things like this do not happen again.
Putting myself in the shoes of the clinician I would have immediately self-reflected to see where I dropped the ball on Josies care. There are no words or actions that can fix what happened to Josie at this point so now to live with the fact that I made mistakes, overlooked important ques, did not advocate for the best for Josie, and was a contributing factor in the senseless death of a child would be too much to bear. There are not enough “I’m sorry” but I would vow to her family to never allow this mistake to happen again. Missing care should have a consequence like any other field does, the depth of the consequence based on the depth of the missing care on my opinion.
References:
Rodziewicz TL, Houseman B, Vaqar S, et al. Medical Error Reduction and Prevention. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK499956/
Post by Amanda Machado
Josie King was an eighteen-month-old who died from preventable medical errors. Some factors that may have contributed to her death include miscommunication among the care team and lack of patient empowerment.
During Josie King’s hospital stay, there was a verbal order for no more narcotics. However, a nurse still administered methadone to Josie. This miscommunication among the care team could have been prevented by limiting verbal orders. Limiting verbal orders and having all orders when possible in the patient’s chart, could prevent any vital information from being left out or miscommunicated during handoffs between the care team. Also, during her stay Josie’s mother noticed her daughters decline and voiced her concerns however time and time again her concerns were disregarded. Patients and healthcare professionals must understand the need to see patients as part of the healthcare team to ensure quality of care and decrease medical errors. A patient empowerment model to prevent medical errors could prevent a similar tragedy from happening.
By placing patient empowerment at the forefront, Sorrel King could have had more power over Josie’s treatment. Regular communication and updates among providers and Josie’s caregiver could have helped. Also, including the family in patient rounds and handoffs could have kept Sorrel King informed and engaged in her daughter’s care decision.
If I was the clinician working in the case of Josie and her mother said, “You did this to her, and now you must fix her,” I would have felt an immense amount of guilt and shame for having failed this patient. I would empathize with Josie’s mother but take responsibility for what happened and make positive changes so this would not happen to another patient again.
It’s important to offer patient and family-centered care so that patients feel respected and included. I would achieve this by updating them frequently on their plan of care, including them in decision-making, and always listening to any concerns or questions they might have.
Persistent quality care problems in nursing practice include personnel shortages and burnout, task overload, a lack of standardized communication protocols, occupational hazards and workplace safety, and administrative tasks and regulatory burdens that extend beyond direct patient care. These issues directly affect patient care and safety.
Unfortunately, there is a culture of missing care due to these nursing quality care issues. There isn’t a single factor responsible for its evolution but a combination of systemic issues such as adequate staffing, resources, workflow and communication issues.
Missed nursing care can be handled by first addressing issues such as staffing and workload. Empowering nurses through regular training and giving them a space to voice their concerns is also a step in the right direction to solving missed nursing care.
References
Nursing OTTP. (2016). IHI Coursera Josie King [YouTube Video]. In YouTube. https://www.youtube.com/watch?v=zrFGHowu3pE
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