Summary
Fifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
Content
On March 4, 2001, George Dover stood outside a Baltimore County home, rang the doorbell and changed the future of Johns Hopkins Medicine.
The director of the Johns Hopkins Children’s Center had come to the home of Tony and Sorrel King to apologise to the grieving parents.
Six weeks earlier, the Kings’ 18-month-old daughter, Josie, had wandered into an upstairs bathroom, turned on the hot water and climbed into the tub. By the time her screams brought her mother, Josie had second-degree burns on more than half of her body. The toddler was rushed to The Johns Hopkins Hospital, where she received skin grafts and healed. Within weeks, she was acting like her old self. But then she developed a central line-associated bloodstream infection—an infection today known to be preventable. The infection ultimately led to septic shock, and Josie King died on Feb. 22.
The day Josie died, her Johns Hopkins-affiliated paediatrician, Lauren Bogue, walked into Dover’s office. She encouraged him to visit the King family and accept responsibility on behalf of Johns Hopkins. The unusual proposal quickly won full support from Johns Hopkins leadership—even its lawyers. Bogue arranged the meeting and accompanied Dover.
On June 2, 2001, a second tragedy occurred. Ellen Roche, a healthy 24-year-old technician at Johns Hopkins’ Asthma and Allergy Center, died of lung failure less than a month after inhaling an irritant medication while participating in an asthma research study. Ten days after Roche’s death, the U.S. Office for Human Research Protections suspended all federally funded human subject research at Johns Hopkins, halting nearly 2,500 investigations for several months.
The two deaths shattered Johns Hopkins, propelling what some consider the most significant culture change in its history.
0 Comments
Recommended Comments
There are no comments to display.
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now