,,,,I'm not finding fault with your case Heartthrob, only the way you choose to degrade an entire facilty.

JOSIE KING

Josie King was 18 months old when she was taken to Hopkins after being scalded in a bathtub accident in February 2001, a year before my encounter with the culture of safety.

“She healed well and within weeks was scheduled for release.” Josie’s mother, Sorrel, writes on her Website, the Josie King Foundation. http://www.josieking.org/page.cfm?pageID=10

But something was wrong. Josie seemed to be very thirsty all the time, eagerly seeking moisture from any available source. Her mother deferred to the experts. Sorrell King knew her daughter was thirsty, and she wanted to give her water, but was told she couldn’t.

The little girl died from dehydration.

The Summer 2004 online issue of Hopkins Medicine features a story called “A Remedy of Errors,” http://www.hopkinsmedicine.org/hmn/S04/feature1.cfm an audacious work of public relations, which I predict one day will make it to the University of Spin as a textbook example of how to write when you’ve been handed a lemon of a story.

“Out of a deadly medical mistake at Hopkins Hospital sprang a patient-safety effort that has united a bereaved parent with malpractice lawyers, physicians and nurses.”

The story starts out with a visit to the home of Josies’ parents by the Director of the Johns Hopkins Children’s Center, Dr. George Dover: “What could he possibly say to this man and woman whose 18-month-old daughter had died at Hopkins just days earlier, not of some rare, incurable disease but of thirst?”

“We knew what had happened,” says Sorrell King. “We wanted someone to tell us why—why didn’t they listen to us when we said something was wrong with Josie, why didn’t they give her something to drink? We were involved with our lawyer then. We were going for it. If George had said, ‘We’re not sure what happened,’ we would have thrown him out.”

George knew what to say.

The Kings had hired Paul D. Bekman to represent them. Hopkins was faced with the nightmare prospect of a junkyard dog like Bekman holding the personal injury lawyer’s Straight Flush: a slam-dunk case involving the death of a child – a child of the upper middle class. “My husband, our lawyer and George were holding me back from going to the newspapers,” says Sorrell. Hopkins was quick to settle for an undisclosed sum and to help set up the King Foundation.

So when Doc Dover visited the King family at their home on that “windy March Sunday,” he was all contrition and generosity – not to say that it wasn’t genuine.

“Remedy of Errors” went on about how patient safety had always been a top priority for Hopkins Medicine, even before Josie King died in their care in such a potentially public manner.

As President of The Johns Hopkins Hospital back in 1999 Ron Peterson was a hard charging executive with an eye for innovation – and he had a special interest in patient safety because his father died by medical mistake. One day he read a report from the Institute of Medicine which detailed the sad state of patient safety in America. One hundred thousand people a year died from medical mistakes – and some of those tragic deaths might have been prevented. According to The Sun, Ron Peterson “understood the report’s call to action.”

A call to action! What was needed was a plan, a grand plan to make patient safety — not merely a top priority — but The No.1 Priority.

Two years later, as Josie King lay dying for want of a drink of water, Peterson and other Hopkins visionaries were “still hammering out their plans” for patient safety. What important business could have been Hopkins’ No.1 priority when Josie King arrived at the Emergency Room — while Ron Peterson and his team were holed up somewhere hammering out their master plan. What was the No. 1 priority at Johns Hopkins Medicine if it wasn’t the safety of the patients?

The Baltimore Sun ran a feature story about the tragedy.
http://www.baltimoresun.com/health/bal-te.sorrel15dec15,0,1054290.story

There was outrage:

“Josie died of a Third World disease — dehydration — in the best hospital in the world,” said Dr. Peter J. Pronovost, a Hopkins physician and patient safety expert, whose father had been the victim of a medical mistake. “How could that possibly happen? The answer is, we’ve created a system that’s allowed it to happen.”

There were mea culpas and calls for accountability:

“This is my hospital. This happened on my watch. This is my responsibility. I’ll get to the bottom of it,” Dr. George Dover said. Dover said what had happened to Josie was a “sentinel event” – an unexpected occurrence resulting in serious injury or death. He said a committee would review, as required, what had happened and recommend ways to correct any problems.

And, to demonstrate sincerity and a willingness to go the extra mile, Dr. Dover promised that the hospital would try not to cover anything up.

Proclamations were issued from on High:

“I want everybody in the hospital empowered to be able to pull a cord and stop the assembly line when they see something unsafe,” said Dr. William R. Brody, president of the Johns Hopkins University.

(Hopkins later had the cord pulled for them in a rare display of pique by the FDA on another matter.)

“By June 2001, four months after Josie died, Hopkins had finished its review and told Sorrel and Tony what they had known all along: Josie’s death had resulted from a total breakdown of the system. Three weeks into her recovery, the child had suffered devastating brain damage after her heart stopped because of severe dehydration. The medical staff hadn’t responded appropriately to the warning signs – her precipitous weight loss, severe diarrhea, intense thirst and lethargy,” according to the Sun.

Dr. Dover may have taken full responsibility for the tragic death of Josie King, but when the internal investigation finally got to the bottom of it all, they found that a temp nurse should take the fall: “the committee concluded that the temporary agency nurse tending to Josie the day her heart stopped should have been more aggressive in alerting physicians to the child’s symptoms.” Richard P. Kidwell, Hopkins’ managing attorney for claims and litigation, said “The information was there, but no one really put it all together.” Kidwell, who reminds me of Lionel Barrymore in “It’s a Wonderful Life,” later revealed that the committee’s investigation had determined that the desperately dessicated Josie King should have been given a drink of water.

However, as the Baltimore Sun said, out of tragedy sprang a passion for safety, and the desire for Johns Hopkins to become the leader in the field. The Josie King Foundation would light the way of safe passage for all the sick and injured in the dicey environs of John Hopkins Medicine.

I agree with you, Pam.

As Hugh Calkins is employed by John Hopkins Hospital and information has availed itself to show that Calkins lied but is being protected by JHH . . . then they are just as responsible.

Ellen Roche

Two months later, in June 2001:

“Johns Hopkins Admits Fault in Fatal Experiment”
http://www.nytimes.com/2001/07/17/health/policy/17RESE.html

Ellen Roche was a healthy 24 year old lab technician. She figured she’d make a few hundred extra bucks by participating in a study. The consent form she signed made no mention of a drug called hexamethonium, which was not approved by the FDA. The principal investigator for the study had checked with Medline about hexamethonium, which would be used to induce asthma-like symptoms in research subjects, but he did not check Google. So, for $365. Ellen Roche inhaled the gas, and then, basically, her lungs shriveled up. She spent several weeks in the ICU before her parents removed life support. Perhaps if hexamethonium had been listed on the consent form as the drug that she would be inhaling, lab tech Roche might have looked it up on Google, where several sites would have told her that she was in danger.

There was outrage, there were mea culpas, and sweeping reforms were promised.

“Her loss can hold meaning for the whole Hopkins family if it reminds us of our obligation to protect the lives of those who seek our help,” said Ed Miller, CEO of Hopkins Medicine.

Three months later, in July 2001:

Hopkins Investigating Study

http://www.nytimes.com/2001/07/31/us/johns-hopkins-is-investigating-study-in-india-by-a-professor.html

“The reports said the doctors questioned whether the researchers received proper permission from patients, whether surgery or other treatments were delayed because of the administration of the experimental drug and whether the drug had been screened for toxicity...”

U.S. Investigating Johns Hopkins Study of Lead Paint Hazard

Four months later, August 2001:

http://www.nytimes.com/2001/08/24/us/us-investigating-johns-hopkins-study-of-lead-paint-hazard.html

The New York Times- “Amid growing concern about the safety of medical research involving humans, the Department of Health and Human Services opened an investigation on Wednesday into a lead-paint study in Baltimore overseen by Johns Hopkins University.

“The study was criticized last week in a decision by the Maryland Court of Appeals, which likened it to the infamous Tuskegee syphilis study decades ago.

”It can be argued that the researchers intended that the children be the canaries in the mines but never clearly told the parents,” Judge Dale R. Cathell said in a scathing decision that compared the Baltimore study to Nazi medical experiments and the study in Tuskegee, Ala., that withheld treatment from black men with syphilis.

“Neither researchers nor parents, Judge Cathell said, have the legal right to put healthy children into a study that offers them no benefit and carries real hazards. Children who ingest lead can suffer brain damage.

“… Suzanne Shapiro, the lawyer for Catina Higgins, one of the mothers who filed suit, said that in May 1994… when Ms. Higgins and her 4-year-old son, Myron, moved into a rented house at 1906 East Federal Street, the lead in Myron’s blood was at a safe level and his mother knew nothing about the study.

”After she moved in, Kennedy Krieger
enrolled her in the study, and she signed the informed consent, but no one ever told her, ‘There’s lead in this house, and it can cause brain damage,’ ” said Ms. Shapiro, who specializes in lead-poisoning cases and has other clients who participated in the study.

Ms. Shapiro said that a month later Myron’s blood contained excessive lead, and that he had since had neurological problems. “

How could I fail to notice, after what happened to me, a facility that seems to just have a sense of entitlement, regardless of life threatening consequences??

I fully understand how it would be very difficult for you NOT to notice.

Wish, people who hear about what happened to me, write to me to tell me what happened to them at Hopkins. Oh, I hear lots of horror stories!!

Mistakes, and deliberate negligence and abuse, happens.

,,,,I'm not finding fault with your case Heartthrob, only the way you choose to degrade an entire facilty""

Pam
Hopefully you aren't defending yourself from
the above comment. Because it is made by a person who GENERALIZES and automatically defends the medical profession regardless of the facts.
[old saying: My mind's made up,don't confuse me
with the facts]

This institution ADMITS to its broken patient safety system - and your dr. was KNOWINGLY practicing in this very environment -
The Head of the Patient safety system - did not disclose the institution's DEFECTIVE patient safety factor and
had you KNOWN of it --I'm sure you would never have consented to treatment there and put yourself in harm's way.

We can only imagine what the person who made
the comment in your title would do
if he or a member of his family one day required treatment at this facility some time in the future.....
Would he just roll the dice???

Perhaps Hopkins may consider a sign in front of the
hospital -
Warning - We cannot guarantee your safety-----------Enter at Your Own Risk!

Something to think about, eh?

It's a little hard not to when HM follows you around trying to challenge everything you say
and Med101 Don't know why I take the bait....... Not for him, but to prove to other forum members just how wrong he is!!

Seems the only reason he came here in the first place was to defend the medical profession regardless of what they did. Look at his posts on the idea of Mare rating JaneQ doctors!!!

Yes I agree -------these posters act more like a "hired gun" but on closer inspection these are rubber bullets! LOL
Please post the link to comments about JaneQ's ratings??

http://www.ratemds.com/social/?q=node/39687

For those with rubber bullets for me - if the rubber bullet bounces back and hits you in the eye, you are encouraged to come to Hamilton to get your eye checked out!

Do you realize, that for every single story you quote, you can google 100's of others supporting the facility? Pick any topic.

I wonder if you could come up with statistics detailing the ratio of successful individual cases to bad outcome ones....

Then a further ratio of actual malpractice claims.

That would be interesting

Now that...is actually funny...nice job.

Harley, what I have shown here are NOT simply malpractice issues, with the exception of the Josie King story. That one they couldn't get out of. The child died of dehydration and it was all over the news. See what they have to do if they just can't get out of it?? They wound up finding a great scapegoat. They blamed it on a tempt nurse!!!

"when the internal investigation finally got to the bottom of it all, they found that a temp nurse should take the fall: “the committee concluded that the temporary agency nurse tending to Josie the day her heart stopped should have been more aggressive in alerting physicians to the child’s symptoms.”

Ellen Roche Hopkins administered a toxic drug to her by inhalation in an experiment. She died. She was a human guinea pig.

U.S. Investigating Johns Hopkins Study of Lead Paint Hazard Families with children were rented homes with varying degrees of lead to study the effects of the lead paint on the children over time. ~ hardly a malpractice case.

My point is that they do have a sense of entitlement. They believe that human beings are dispensable for purposes of learning.

There is a difference between Johns Hopkins Hospital Administration and the many different departments at Johns Hopkins - as well as the overall culture of the working environment. Just as there is a difference between doctor to doctor. We are not equal - in intelligence, in ethics, in responsibility and conscientiousness.
It seems that ALL corporations/administrations close ranks and stand behind a cadre of lawyers and become most inhuman when being human is the exact thing they should be after causing a disaster. They themselves should not stand behind statistics - they should have a zero tolerance policy to lapse in judgement concerning ethics, responsibility and conscientiousness.
If Harley's statement was true, about the statistics, you could say of a cheating husband, "He only cheats 1 out of 23 hours a day, so what's the problem? Look at how good he is the rest of the time."
Doesn't make much sense.
But we also need to try to understand Harley. He finds comfort in statistics. If only 1 in 500 people gets MS, the one who has it cannot be ignored because the other 499 didn't get it. The one with MS doesn't care about the other 499. And if you or a loved one are the ONE, hearing about the other 499 doesn't help your situation.
So instead of railing against Harley, why not point out that we're here on a human level. And that's where we are discussing this topic, as caring human beings, not statistical anomalies. As a matter of fact, may I suggest that when Harley isn't on the human side of the game, we just post the response, "We are discussing this topic as caring human beings, not statistical anomalies. Love to have you join in."

That husband, when caught cheating faces consequenses.

Blanket statements purporting the encouragement of cheating buy the wife of his friends, would be wrong.

Bravo!!! I love it, love it, love it!!!

Statistics, save and heal much more then emotions do.
Statistics determine what medications work, what therapeutic options are best.

Do you think driving around and approaching a green light...are you using statistics to estimate whether the car opposite you will stop for the red light, or emotions?

It's the basis most all that runs the world. Emotionality crtainly has it's place though.

I don't understand your reply. Can you explain it to me?

But Harley, "We are discussing THIS topic as caring human beings, not statistical anomalies. Love to have you join in."

Why do we seem to end up with Harley being the center of attention no matter what the topic?

We are now, apparently, discussing cheating spouses.

This happens far too frequently.

I believe that the death or injury of
ONE patient DOES degrade an entire facilty.

If I was being wheeled to surgery while another
"dead" patient was being wheeled out - should I say
to myself - well.......statistically - that probably won't happen to me???

This is a switch. Perhaps I should comment instead on the CMPO (or whatever the letters) and vision problems?

QUESTION: Why do we seem to end up with Harley being the center of attention no matter what the topic?

ANSWER: Because HE DEMANDS it!

SOLUTION: I/V drip 24/7 for "Center Stage" disease?

Your insecurity issues and desires to always be right should be addressed in another topic, Harley.

I agree with you, Wisher.

I'm sorry wisher. Bad attempt at a joke. was trying to keep it light. You've done a nice job lately of moving on and that comment didn't help.

It was in insensitve comment. I have no excuse.

I'm sorry

The actions of the staff at the facility are responsible for the degradation of said facility....not the patients who must deal with the outcome of the actions of the staff.

Because he's an infectious disease. Grab a mask.

Indeed.

http://www.youtube.com/watch?v=b_3mUNAJLVk

You're forgiven. And I take back what I wished for your grout.

Excellent. Thank you for accepting my apology.
Can you put in a good word for me and get me reinstated?

Oh C'mon harley - it's not like you're 666. Just 6.
That, of course, could be some kind of logical fallacy on my part, but Jane is not here to question whether or not it actually is.
I'm sure that JaneQ would have a lot to say.
She is greatly missed.
And, you need to be respectful of that.
So - it looks like you are "6" for now, and I think that you should make an effort not to get up to 666.

Talk about being dense (and I don't mean wishandaprayer).

Everyone knew that - right?

I would bet the answer to your question, wishandaprayer, is an resounding YES!

Wow,Harley,am I seeing what you accused Blake of doing?? Kissing booty. I didn't think the mere words could upset anyone.

Better be careful Harleyman VI

Louis XVI was guillotined you know.

You only have X to go.