Exposing Preventable Medical Errors Subject of PBS Series
“Silent Killer” shows how families and health care professionals are working
together to stop needless loss of life in American hospitals
In the chaos of American hospitals, a silent killer lurks hidden from view: medical errors. Rarely are these errors exposed and discussed openly so that everyone can learn. In “Silent Killer,” the first program in the four-part PBS series, Remaking American Medicine™…Health Care for the 21st Century, Sorrel and Tony King of Baltimore, Maryland come face-to-face with the dangers of hospital care when their youngest daughter, 18-month-old Josie, is killed by a medical error at America’s top-ranked hospital, Johns Hopkins. “Silent Killer,” appearing on PBS on Thursday, October 5, at 10 p.m. Eastern time/9 p.m. Central, chronicles how the Kings, Johns Hopkins and leaders such as Dr. Donald Berwick are determined to eliminate the preventable mistakes occurring at an alarming rate in hospitals around the country.
In 2001, Josie King wandered away from her parents, crawled into a bathtub at home, turned on the hot water and was seriously burned. After nearly two weeks of being nursed back to health in the Pediatric Intensive Care Unit, Josie was well enough to transfer to a step-down unit in preparation for going home. Her central line that delivered nutrition and fluids was removed.
That’s when Sorrel began noticing something wrong. Her daughter seemed extremely thirsty all the time and Josie’s weight suddenly dropped. But when Sorrel repeatedly raised concerns, the medical staff ignored her.
Josie suffered a cardiac arrest caused by severe dehydration and the possible misuse of narcotics. By the time help arrived, it was too late. Josie died at Johns Hopkins on February 22, 2001.
Josie’s death came just two days before she was to be discharged home. The Kings were stunned. “Medical errors? They’re not going to make a mistake,” Sorrel recalls thinking. “These people are the smartest of the smartest.”
“I’d never really even heard the term, medical error, or knew that this was going on,” adds Tony.
In fact as many as 98,000 people die each year in American hospitals due to medical errors, more than auto accidents, breast cancer, or HIV AIDS.
Shortly after Josie’s death Children’s Center Director Dr. George Dover came to visit the Kings. “I was there to say that is was the institution's fault that their child had died, and that these are the things that we were doing to understand how it happened and what would happen next.
The root cause of Josie’s death, Hopkins determined, was a breakdown in communications between the various caregivers and the Kings. Upwards of 60 percent of all medical errors can be traced to poor communications.
For Johns Hopkins, Josie’s death served as a wake-up call that the institution had to change dramatically. At stake were literally tens of thousands of lives every year. “It was probably the lowest point that I have been at this institution, that the whole institution knew something was dreadfully wrong and that we had killed somebody,” says Dr. Ed Miller, CEO of Johns Hopkins Medicine.
With a settlement from the hospital, the Kings set up a unique patient safety foundation named after their daughter that would initiate or fund programs that would help eliminate unnecessary deaths. And then they did something truly remarkable. The Kings approached Hopkins and suggested working together to tackle the problems of medical errors head on. Johns Hopkins set out to change the way it delivers care to become safer, and Sorrel King emerged as a leading advocate in a burgeoning patient safety movement.
“I've never had an experience where someone who was suing us picked up the phone and called and said, ‘All right, now let's put the claim aside. What are we going to do to make things better for other families?’" says Rick Kidwell, the Johns Hopkins attorney who handled the Kings claim.
In order to initiate changes and to create an environment of more open communications among staff, Johns Hopkins turned to Dr. Peter Pronovost, a staff physician who had begun making a national name for himself as a patient safety expert.
“No one caregiver alone can carry out the plan. It requires, truly, a team effort from the surgeons to the nurses and respiratory therapists. We all need to make sure we are aware of the same plan,” said Dr. Pronovost.
Sorrel King’s advocacy has lent a rare and valuable patient voice to the safety movement, and she has been embraced by its leaders, including Dr. Donald Berwick.
In 2004, Dr. Donald Berwick, one of the pioneers of health care quality improvement, invited Sorrel to take the stage at his organization’s annual meeting alongside several of America’s most powerful health care leaders including the heads of the American Medical Association, the American Nurses Association, the Centers for Medicare and Medicaid Services, and others.
When it came time for Sorrel to speak, she surprised the thousands of health care professionals in the audience that day by suggesting a radical notion: allow patients to call for an emergency rescue squad called a rapid response team to come to the bedside when a patient is in distress.
ami Merryman, Quality Leader at Shadyside Hospital in Pittsburgh, Penn. was moved by Sorrel’s appeal. “Sorrel said, ‘If there had been a rapid response team at the hospital that I had had the opportunity to call myself, I believe my daughter would be alive today.’ I thought to myself, isn't that so true.”
As a direct result, Shadyside has become the first hospital in the country to allow patients or their families to call rapid response teams. It is called Condition H (H for Help). Says, Merryman, “Initially there were concerns expressed by doctors and nurses. But I believe that Condition H is an overriding safety system that really challenges an organization to put the patient first.”
In the second half of “Silent Killer” viewers will learn about a remarkable effort initiated by Dr. Donald Berwick, founder and president of the Institute for Healthcare Improvement (IHI). For the past two decades, Dr. Berwick has helped shape and lead a national movement to eliminate medical errors.
In 2004, Dr. Berwick launched the most ambitious patient safety effort in the nation’s history, the 100,000 Lives Campaign. More than 3,000 hospitals have signed on to use the best-known practices to treat patients following a heart attack, to prevent infections and medication errors, and to save lives by using rapid response teams.
“We don't have to accept unnecessary death in American health care. We can decide to stop a good deal of it and that's what the campaign is trying to do. We said, ‘Let’s save 100,000 people who otherwise would die in hospitals.’ It can be done. I don't have any doubt about it,” argues Berwick.
For the family of Mary McClinton, Dr. Berwick’s campaign came too late. Mrs. McClinton died due to a preventable medical error at Virginia Mason Medical Center in Seattle, Washington. Rather than hide the mistake, the hospital took a cue from the way the Kings and Hopkins worked together. It admitted its error, apologized to the family and has, among other things, initiated an award in Mrs. McClinton’s honor recognizing employees for improving health care quality.
“If we can prevent even one family from going through the type of experience that we had it’s extremely important to us. We can have a partnership with Virginia Mason because the ultimate goal is patient safety,” said Mrs. McClinton’s son, Gerald.
“Silent Killer” was produced, directed and written by Marc Shaffer.
Crosskeys Media®, producers of Remaking American Medicine™…Health Care for the 21st Century, is a group of highly accomplished filmmakers with a long history of creating award-winning theatrical films, television programs, documentaries and non-broadcast videos. Frank Christopher is Executive Producer and Matthew Eisen Co-Executive Producer. Peabody Award and Emmy Award winner John Hockenberry, formerly of NBC and NPR, serves as the series host.
Funding for Remaking American Medicine was made available by lead sponsor the Amgen Foundation with major underwriting from The Robert Wood Johnson Foundation®. Additional funding was provided by the Nathan Cummings Foundation.