What Happened to Josie?

Learning Objectives: At the end of this activity, you will be able to:

  • Discuss factors that contribute to avoidable patient harm, even at renowned facilities.
  • Explain how patient-centered care can help prevent adverse events.

Description: In 2001, 18-month-old Josie King died of dehydration and a wrongly-administered narcotic at Johns Hopkins Hospital.  How did this happen?  Her mother, Sorrel King, tells the story and explains how Josie’s death spurred her to work on improving patient safety in hospitals everywhere. 

[This is an excerpt from a speech given at IHI’s National Forum in 2002. It is copyrighted material of the Josie King Foundation. IHI received special permission to use this excerpt in this format. For more information on this speech, please visit http://www.josieking.org/.] 

Start learning how to improve health care and prevent medical error in our free sample course, QI 102: How to Improve with the Model for Improvement.

Discussion Questions 

  1. ​What factors contributed or may have contributed to Josie King’s death?
  2. With those contributing factors in mind, how could Josie’s death have been prevented, and what process changes would you recommend to prevent a similar tragedy from occurring?
  3. How could the hospital and its providers have given Sorrel King more power over how Josie was treated?
  4. Put yourself in the shoes of one of the clinicians who cared for Josie. How would you have reacted when Sorrel said, “You did this to her and now you must fix her”?
  5. If you plan to be a clinician, what are specific things you can do to make patients feel respected and included in decisions about their health care? 
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