Josie Story

According to the Joint Commission (2006), a sentinel event is as, "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or "risk thereof" includes any process variation for which a recurrence carries a significant chance of a serious adverse outcome." Sentinel events signal a need for immediate investigation and response. The importance of sentinel events in providing safe nursing care includes: improving quality of patient care, increasing the awareness of sentinel events, upholding the public trust of the medical system and understanding the reason behind the event and restructuring the organizations protocols in possible future events.

As the safety officer appointed by Doctor Dover, the head of Johns Hopkins Children's Center, I led an investigation in 2001 pertaining to the death a young girl by the name of Josie King. This event was termed a sentinel event because of a possible medical error. The first step into my investigation was to gather information from the mother that led up to the death. The incident began in late January 2001, when Josie was brought to the hospital by paramedics due to burns over her body from falling into a bath tub full of hot water. Josie was taken from the emergency room to the pediatric intensive care unit, were she was given pain medication and an IV was established to put her into a drug induced coma. On day nine, Josie was moved to the step down unit. On the way down, while Josie was resting comfortably, the nurse pushed the pain button. Mrs. King questioned the reasoning for the pain medication and if it could be given less. Shortly after, Josie was taken off the morphine, given methadone and began to wake up. By day ten, Josie was fully awake and eating. On day fourteen doctors stated that Josie would be discharged in a few days. The same day, Josie began crying every time she saw water, but the nurse stated that she could only have ice chips. Later that day, her central line was removed. That evening, Josie appeared thin, pale and tired. The nurse was asked if she would call a doctor and she stated that Josie was fine and she was just tired. At 5:30 a.m. on day fifteen, Josie's mom walked in and found her unresponsive. Josie was given a shot of Narcan, in which her symptoms improved. Later, the pain management team came and said that Doctor Paidas had given orders for no more methadone. At 1:00 p.m. the nurse walked over with a syringe of methadone, Mrs. King pleaded with her not to give her the medication. The nurse replied that the orders had been changed and continued to administer the medication. Right after the medication was administered Josie went into cardiac arrest. The doctors were able to revive her, but she died the next morning due to multi-organ failure.

I used the information provided by Mrs.