Medication Safety: Josie's Story

Medication Safety

Tony and Sorrell King had no idea when they moved from Virginia to their new home in

Baltimore, Maryland with kids Jack, Eva, Relly and Josie that their story would shake the entire

foundation of the health care system. After eighteen month old Josie suffered severe burns from a household accident, her parents rushed her to Johns Hopkins hospital where the family instantly fell in love with the hospital itself, as well as the competent staff of nurses and doctors employed there. Throughout beginning of their stay at the hospital, the King’s had referred to Hopkins as their second home. Sorrell had slowly built up close relationships with the staff, particularly the nurses, and even became active with Josie’s plan of care.

It wasn’t until
Josie began showing signs of extreme thirst due to dehydration that Sorrell began to voice her concerns to the staff, all which became ignored. Josie was then administered a lethal dose of methadone for pain, which resulted in her death by cardiac arrest. After being offered a settlement by Hopkins the King family refused, wanting to bring light to what happened to Josie, as well the dangers of medication errors to patient safety.
One important aspect identified after reading Josie’s Story would be the methadone which was used trying to manage Josie’s pain.

After her initial admittance to Hopkins, Josie was originally prescribed morphine, a powerful narcotic, to help manage her pain. The amount and frequency in which the nurses administered the drug made Sorrell feel uncomfortable, so eventually she was able to have Josie taken off the morphine and instead be given a similar, yet weaker, opioid drug called methadone. As Josie was put on a weaker pain medication, she began exhibiting signs of a drug reaction such as vomiting and fever. After running tests, doctors realized Josie had come down with an infection and began to give her antibiotics. A while

later,
Sorrell began to notice her daughter’s displaying signs of extreme thirst. Eventually, Josie became unresponsive, and doctors feared that she may have been over sedated by the methadone.
She was then given a shot of Narcan, which is the reversal for opioid depression. Josie became more responsive, and it was then decided by doctors that she would receive no narcotics until instructed otherwise. However, there is a great risk of withdraw from narcotics, particularly morphine, and Josie’s pain management team worried that skipping the dosages of methadone would send her into distress. Methadone is a widely known pharmacologic treatment for opioid dependence by occupying receptor sites on the brain (ICER, 2014). Since Josie was still being weaned off her prior morphine dose, it was decided by the pain management team that she would be given another dose of methadone. Against Sorrells’ wishes, a nurse administered the medication and soon after, Josie’s heart stopped. Even though she was revived, extensive and irreversible brain damage had occurred, and eventually Tony and Sorrell King had to make the devastating decision to let their eighteen month year old daughter go.
Another important aspect from Josie’s Story would be Johns Hopkins hospital’s lack of showing responsibility for the death of Josie King.

After Josie’s death, the King family was wrought with grief, sadness, and most importantly anger. Sorrell wanted to ensure that the hospital and staff never forgot what happened to Josie and their role in her death. As protocol, an investigation was done surrounding the events leading up to Josie’s death. A team was assembled, and eventually Tony and Sorrell were called into Hopkins to hear what they had to say. It was stated that the methadone given had nothing to do with Josie’s cardiac arrest and that it was merely because of complications. However, when Sorrell accused the team of knowing that the cause of Josie’s death was a combination of dehydration, administration of a narcotic and a lack of communication between staff, no one could argue. Eventually, Hopkins offered the King family a hefty settlement, which the family refused. Instead, the King family wanted to educate people about the danger of medication errors and how they can affect patient safety. Medication errors leading to patient harm are more common than many in the world may want to believe. One reason behind these errors is a lack of communication. Not only do all attending staff members need to communicate but their must be open communication between the patient and doctors as well. Dr. Marty Makary, a surgeon at Johns Hopkins hospital has stated that

“it's also important to increase the awareness of the potential of unintended consequences when doctors perform procedure and tests. The risk of harm needs to be factored into conversations with patients (Allen, 2013).” Essentially, the more communication that there is between everyone involved in the plan of care for a patient, the more likely it is for there to be fewer medication errors. If an individual is informed, they are able to voice their concerns with the doctors and nurses, and thus bringing more awareness to the issue at hand. With Josie King, had there been more effective communication between the pain management team, doctors, nurses and the King family, there is a much greater chance that the error could have been avoided.
One aspect of Josie’s Story in which I did not understand was the fact that Josie’s state of dehydration seemed to be vastly ignored by the nurses and doctors at Johns Hopkins hospital. It is stated by Sorrell in the book that she believes Josie’s cause of death to be a combination of
dehydration and narcotic use. When Josie started to show signs of dehydration, why was nothing
done about it? It is not uncommon for burn victims to be more prone to becoming dehydrated. In
burns, fluid is lost through the skin, eventually leading to shock. Intravenous fluids are used to
help fluid replacement and are often used for treatment of dehydration (Ehrlich, 2013). Johns
Hopkins is one of the top hospitals in the world, and to think that the doctors and nurses there would not be able to pick up the symptoms of what was going on with Josie is unbelievable satisfactory. Whenever Josie began to exhibit signs of extreme thirst, why were the nurses so apprehensive as to whether or not they should be giving her any type of fluids? Eventually when Josie was given an oral antibiotic to help fight an infection and her IV line was taken out, why wasn’t the fact that she was dehydrated taken into account?
An additional point from Josie’s Story in which I would like to know more about would be Josie’s burns and whether or not those burns were properly taken care of by the staff at Johns Hopkins using sterile techniques. In the novel, Josie suffered from second degree burns after she climbed into the family’s upstairs bathtub by herself and turned on the hot water, scalding her skin. The eighteen month old had second degree burns over sixty percent of her body. “Second degree burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering (Heller, 2012).” These more severe types of burns are likely to put patients, especially children and older adults, at a great risk because they inhibit the skin’s basic and most essential functions; such as being a first line barrier against infections and retaining optimal body temperature. Skin grafting can be necessary for these types of burns. A skin graft is a procedure where a portion of skin from a patient’s body is taken and then placed on a section of their burned skin (UW Health). Josie’s burns were severe enough that skin grafts were necessary, and the pain that she suffered from the burns and procedures were enough to cause her to be placed on morphine and later methadone. It poses the question of infection control, however, because when the staff went to change the dressings on her burns, was sterile techniques used? Proper hand washing and sterile technique are fundamental parts of the healthcare system as well as infection control. Since Josie acquired an infection closer to the time of her cardiac arrest, was it due to improper technique by not keeping her wounds clean?