The story of Josie King

Why do people file medical malpractice suits? One reason is to get answers about what happened to result in the injury. Another is to prevent the same thing from happening to another person. Although risk managers, practitioners, and administrators may make changes after a bad outcome has occurred, it is not often that the plaintiff gets the satisfaction of knowing that. It is even rarer the terms of a settlement to solidify a plan to share the details of a medical tragedy.

A recent Oregon case shows the power of sharing a lesson that will protect other patients. The plaintiff was an 8-month-old infant who entered a hospital for removal of a cyst that extended through his nose to his brain. The surgery was without complications. After surgery, the infant had fevers, pneumonia, and showed signs of a possible cerebral spinal fluid leak. The discharging physician was a first-year resident; the attending neurosurgeon did not see the infant on the day he was discharged. Eight hours after discharge, the infant was taken to the emergency department of another hospital because he was vomiting and lethargic. The emergency department physician called the defendant hospital and was advised that the infant was probably having a medication reaction. The parents returned eleven hours later when their child was profoundly ill. There was no clear evidence of a systemic infection and possible brain damage.

The infant was emergently transported back to the defendant hospital. He was diagnosed with meningitis, brain damage, and organ failure and suffered a stroke. He requires a ventilator twelve to twenty hours a day, is tube fed, and without effective use of his legs or left arm. He is profoundly developmentally delayed and does not talk. A $12.2 million settlement was reached. The hospital also committed to using the case as a teaching example for its residents for the next ten years and to provide certification of this to the plaintiff’s parents each year from the president of the university.

Source: Lewis Laska, “Infant discharged following brain surgery without being seen by anyone other than junior resident”, Medical Malpractice Verdicts, Settlements, and Experts, February 2009, page 19

The power of sharing the lessons learned from a tragedy of this nature is huge. Unfortunately, it is rare for plaintiffs to achieve this kind of gain. I can think of another case – one we handled at Med League in which this occurred. I was involved in a Philadelphia case of a young man who developed leg pain and shortness of breath on the day of discharge. The nurse did not inform the physicians, and the man was discharged via telephone order. He collapsed at home and died from a pulmonary embolism. As part of the settlement, the hospital made a policy that a patient had to be seen in person on the day of discharge. They also agreed to use this case in teaching each group of interns and residents.

Anyone not familiar with the story of Josie King, an 18-month-old child who died as a result of medication error, should visit the Josie King Foundation. I heard Sorrel King, Josie’s mother, talk three years ago. Her story lingers. Sorrel took the settlement money provided by Johns Hopkins, the hospital where the incident occurred, and put it back into patient safety efforts. Her work has saved lives of people all over the world. A new book pictured above, has just been released, which describes her crusade.

The key to educate, change, and inspire healthcare professionals with lessons learned so that deaths and injuries make a difference in daily practice.