For the next two weeks, we will be discussing Errors. This is a very painful subject. As I discussed in our first class, I experienced the emotional consequences of errors and oversights during Mary's illness. But let's review the story of Josie King. This story again illustrates the devastating consequences of medical errors. And sadly, unlike Mary's case, these errors were not reversible. >> Josie was 18 months old. She had brown eyes and light brown hair. She loved to dance and had just learned to bounce on the trampoline with her older siblings Jack, Relly, and Eva. She had just learned to say I love you. In January of 2001, Josie was admitted to Johns Hopkins after suffering from first and second degree burns from climbing into a hot bath. She healed well and within weeks was scheduled for release. Two days before she was to return home she died of severe dehydration and misused narcotics. I would like to take you through the events that results in this needless tragedy. Josie spent ten days in the PICU. I was by her side everyday and night. I paid attention to every minute detail of the doctors and nurses care and I was quick to ask questions. I bonded with them and was in constant awe of the medical retention she received. Every time Josie moved or fussed someone would be quick to push her pain button. I tried rubbing her head and found that often this would settle her. Much to our relief, Josie was experiencing a quick recovery. Her burns were healing beautifully. She was sent down to the intermediate care floor with expectations of being sent home in a few days. Her three older siblings prepared for her welcome home celebration. We were told that no one had ever been sent back up to the PICU. The following week her central line had been taken out. I began noticing that every time she saw a drink she would scream for it and I thought this was strange. I was told not to let her drink. While a nurse and I have her a bath, she sucked furiously on a washcloth. As I put her to bed, I noticed that her eyes were rolling back in her head. Although I asked the nurse to call the doctor, she reassured me that oftentimes children did this, and her vitals were fine. I told her Josie had never done this, and perhaps another nurse could look at her. After yet another reassurance from another nurse that everything was fine, I was told that it was okay for me to sleep at home. I called to check in two times during the night and returned to the hospital at 5:30 in the morning. I took one look at Josie and demanded that a doctor come at once. She was not fine. Josie's medical team and administered two shots of Narcan. I asked if she could have something to drink. The request was approved, and Josie gulped down nearly a liter of juice. Verbal orders were issued for there to be no narcotics given. As I sat with Josie, I noticed that the nurse on morning duty was acting very strangely. She seemed nervous, overly demonstrative, and in a hurry. Uneasy, I asked the other nurses about her. And they said she had been a nurse for a long time. Still worried, I expressed my concern to one of the doctors, and he agreed that she was acting a bit odd. Meanwhile, Josie started perking up. She was more alert, and had kept all the liquids down. I was still scared and asked her doctors to please stay close by. At 1 o'clock, the nurse walked over with a syringe of Methadone. Alarmed, I told her there had been an order for no narcotics. She said the orders had been changed, and administered the drug. Josie's heart stopped as I was rubbing her feet. Her eyes were fixed and I screamed for help. I stood helpless as a crowd of doctors and nurses came running into her room. I was ushered into a small room with a chaplain. The next time I saw Josie she'd been moved back up to the PICU. Doctors and nurses were standing around her bed. No one seemed to want to look at me. She was hooked up to many machines and her leg was black and blue. I looked into their faces and said to them, you did this to her, now you must fix her. I was told to pray. Two days later, Jack, Relly, and Eva were brought to the hospital to kiss their beloved Josie goodbye. Josie was taken off of life support. She died in our arms on a snowy night in what's considered to be one of the best hospitals in the world. Our lives were shattered and changed forever. Josie died from severe dehydration and misused narcotics. Careless human errors. On top of our overwhelming sorrow and intense grief, we were consumed by anger. They say anger can do one of two things to you. It can cause you to rot away, or it can propel you forward. There were days when all I wanted was to destroy the hospital and then put an end to my own pain. My three remaining children were my only reason for getting out of bed and functioning. One day I will tell them how they saved my life. Tony and I decided that we had to let the anger move us forward. We would do something good that would help prevent this from ever happening to a child again. >> Why didn't Josie receive oral fluids after her central line was removed? Why was Josie receiving narcotics when her wounds were nearly healed and her mother noted that she could be comforted by a rub on the head? [COUGH] Why didn't the nurse listen to Josie's mother about the discontinuation of narcotics and call the physician for clarification? Why was the verbal order to discontinue narcotics not converted to a written order? Why didn't anyone act on Josie's mother's concern that Josie looked very ill? We need to continually as why. I want to share another personal story. How does a middle aged healthy physician lose his leg? On September 18th, 2012, I underwent and above-the-knee amputation. The vascular surgeons who cared for me were dumbfounded. I had no risk factors for vessel blockage. My blood cholesterol was low. I had no evidence of diabetes. No evidence for excess clotting of my blood. And furthermore, I exercised vigorously nearly every day. Studies of my arteries revealed that all the vessels below my left knee were irreparably closed off, while the remainder of my vessels were normal. The only explanation, this had to have been caused by a local injury to the arteries in my left leg. But what had happened to my left leg that had not happened to my right? The only difference had been a left Achilles tendon repair in 1995, 17 years earlier. I reviewed the dictated operative report and realized that the surgeon had used a tourniquet above my left knee to prevent any bleeding. The surgery had been complicated and the tourniquet had been left in place under high pressure for a very prolonged period, probably over two hours. The pathology of my amputated leg revealed extensive scarring of two out of the three arteries below my knee. Scarring that took many years to develop. Consistent with arterial injury at the time of surgery. The injured vessels had progressively scarred to the point that they closed off leaving now vessels to bypass. The only solution was an amputation. And it is clear to me that I lost my leg as a consequence of a tourniquet being left on it for too long. My leg was lost as a consequence of an error. What did this error cost? My insurance paid $138,903 and I paid $55,000, for a total of nearly a $195,000. Not to mention missing six months of work, six months of physical therapy, and great emotional and physical stress for both me, and my family. I had many set backs and many doubts along the way, but I have bounced back, and I am back to full time work. I am grateful to be able to present this course to you. I've been unlucky to experience two life changing errors. And these events further reinforce my dedication to proving how we care for patients. And as I emphasize in my introduction to the course. I cannot improve the heath care quality alone. It will take a large army of patients, caregivers and administrators to improve our systems. And I am depending on you to help. One final thought. Safety is a key component of quality. And if the systems of patient care were highly efficient and reliable injuries and death would be far less common. We can look to the auto industry again. In the 1970s and 1980s Lemon Laws were passed in many states, because too many customers, when they purchased new cars, found that their cars had multiple defects that made them impossible to repair. They were termed Lemons. The exact derivation of the name is unclear, but probably it refers to the fact that customers who purchased such cars were bitter. Just like the taste of a lemon. Lemon Laws force the manufacturer to buy back these seriously defective, newly purchased automobiles. With the advent of Toyota production system, the reliability of automobiles has dramatically improved and lemons are almost unheard of. When it comes to health care, defective systems and errors cause damage that cannot be made whole by money. And there is no buying back a life. As my personal experiences and those of millions of others show, the stakes are far higher in health care. And that is why improving health care quality and safety are so very important. There's a website included in the course materials, victims of medical errors, as well as a web address of a video describing a very poignant story of Jess. I hope you'll have time to read this material as well. These personal stories emphasize urgency of the problem. The time to improve health care delivery is now. Thank you.
