Welcome to the Medical Legal Podcast, where healthcare meets the law. I'm Shawna Butler, nurse attorney. In each episode, we explore gripping real life stories at the intersections of medicine, ethics, and justice.
From headline-making cases to the behind-the-scenes legal dilemmas that healthcare workers face every day. In big communities and smaller, lesser well-known ones. Whether you wish scrubs or a suit, these stories are compelling.
thought-provoking, and deeply human. Let's begin.
How would you feel if a concern that you brought to a healthcare clinician's attention was not addressed?
And it resulted in a tragic outcome for your loved one.
Alternatively. How would you feel as the clinician who did not acknowledge the concern and harm resulted to that patient?
This is a case that we can all see from various sides of the situation. It's an older case from 2001.
It is one of the earlier ones that I learned about that led me into risk management and patient safety.
I wanted to take part and be part of the change that would improve and reduce healthcare errors.
I think of this mom and baby often. If you cannot handle a sad case today, take a break and come back when you can. It's okay. We all can, every day, hear negative things. I promise there is some glimmer of light at the end of the tunnel.
This will allow you as a loved one of a patient to advocate for them, and as a clinician to take a step back when necessary to listen to valid concerns. Stick around, we will cover that in this episode. You can find My Criminalization of malpractice.
On my site at nurseattorneyeducator.com. That's a course you can take that includes continuing education units as well. Let's get started. Josie King was an 18-month-old beautiful girl with no known health issues.
She was taking a normal bath, as one would as a toddler, when she was badly burned.
It was one of those unexpected events that occurs on a randing Tuesday afternoon and turns your life upside down.
If I remember correctly, the water was allowed to go to a level of heat that is not illegally acceptable standard.
There are legal standards for high and low levels of water temperature. Heat can go up to this and down to that, and sadly, this was not even the worst event that occurred to this poor family.
The burns were so severe that she had to be admitted to the PICU.
That is a pediatric intensive care unit for those who may not be familiar with all the various acronyms in healthcare.
The burn is not the crux of the story. It is the medical care received after her burns that led to the event that we will discuss.
As she was getting close to being discharged, and she was beginning to heal about 2 weeks after the burn, sadly, she experienced a medication error that would turn the whole family's life upside down.
She was released from the PICU and sent to another pediatric unit at intermediate-type unit, and at this time, she had an undetected central line infection and was experiencing dehydration. They were trying to figure out what was going on with her, but she was improving. They removed the central line, she was getting better, and thought maybe she did have an infection that she, you know, had acquired at the hospital.
So, it was removed, but at this point, the dehydration was so severe that she would suck on a wet washcloth, trying to hydrate herself.
This is a significant symptom to pay attention to, especially for our little ones who cannot always articulate their issues, pain, or discomfort.
If she saw a drink, she would scream for it. Josie's mom, Sorel King, actually inquired about this and was told it was normal. No, it⦠Symptom for Josie, and not one that her mother had seen her experience before.
And the fact that it was new is really what should have triggered a response from the healthcare team.
Sorrel, her mother, stayed with her daughter every minute of her hospitalization.
At this point, she was encouraged to go home, as we nurses often tell the loved ones of our patients, so they can care for themselves. But I can see why sometimes they don't, and especially when it's a little one. They told her to go home and get some rest, and she did just that.
She returned back to the hospital, bright and early at 5 AM, and she knew something was immediately wrong and had the medical team notified. Josie just didn't seem right, and we know that moms and parents and caregivers of our little ones know them the best.
Patients know themselves the best, and we should always listen to concerns.
They end up administering her Narcan. She had been receiving some narcotic pain relief for the burns, and she requested juice. They did allow her some juice, and she gulped down an entire liter of juice. This is a lot of volume for a toddler.
To consume so quickly, and again, should be a sign and a trigger for further follow-up.
Verbal orders were also provided at that time. No more narcotics.
Presumably, she had gotten better after Narcan, which we know, or some of us may not, it's an antidote for an opioid potential overdose, right? And maybe we got a little bit too much of a dose, and it helps us kind of go back to ourselves.
So the plan was to hold them for the future, to allow her to improve, continue to heal, and ultimately be discharged.
She was on the right path. She seemed to be doing a little bit better. Her mom continued to stay by her side.
You know, she had drank the juice, she was getting more alert after she received the Narcan.
Later that afternoon, a nurse that Sorrel, her mom was not familiar with came in to administer methadone.
Sorrel told the nurse, well, there was an order for there to be no more narcotics. The nurse said the orders had been changed and gives Josie the injection of methadone, dismissing Sorrel's concern.
This is another red flag time, right? This is sadly where Josie's heart stops. Sorrel is then ushered out of the room so they can attend to the child and provide emergency care.
The next time she was able to see her daughter was back in the PICU. That is the pediatric ICU that she had been previously transferred out of, right? To go back to an intermediate.
more standard unit, because she had improved so much. Now she was worse than when she was admitted with severe burns.
She was hooked up to so many machines, she looked awful. Sorrel, it was breaking her heart to see her daughter like that.
Josie sadly, tragically dies two days later in her mom's arms.
Later, it was discovered that she did, in fact, have a hospital-inquired infection that central line infection.
that we talked about earlier. She was severely dehydrated and had been given improper narcotics. That was the dose of methadone that Sorrel questioned when the nurse came in.
This was a truly horrible cocktail of all of the worst possible things that can ever occur.
happening simultaneously, like that saying, the perfect storm. It's when the Swiss cheese lines up, and the holes, they all go through.
What can we learn from this? Besides it breaking our hearts and being devastating in something that no family member, a parent should ever have to experience?
What I say to my students, as the clinician, take a beat.
If somebody questions something, we may get frustrated, we may have, you know.
very assertive family members. Try to take a step back and remember they're doing it because they love their loved one. They're stressed out, they're overwhelmed. We often see people on some of the worst days of their lives.
Take a beat. If somebody questions something, we may be busy and overwhelmed and have a million things to do, but sometimes if we take a minute and confirm their concern, we could prevent something catastrophic.
If this nurse took a minute and said, oh, I didn't hear that, let me go back and double check. Thank you for telling me that." And then inquiring further, "Well, what happened the last time she received a narcotic? What are her other symptoms? Is she in pain? Maybe she wanted to relieve the patient's pain and wasn't taking everything into consideration.
They had a verbal order for no narcotics, but that must not have been committed to the medication errors, whether written or electronic, since this happened a while ago.
Did the sucking on cloths and drinking of a liter of fluid not get passed on the subsequent shifts?
If she had an infection, did that lead to her dehydration? It certainly wouldn't have helped it, but was it known?
Were they taking her vital signs? How was her temperature? Did she have a fever? Did she have a high white count, which is a white blood cell count, and if you have a high one, it can be an indicator of an infection, right? Your white cells are fighting that. That's your immune system.
Did she have other infectious symptoms? Was anybody putting all of this together? And why was it not passed on to this one nurse that had administered the methadone?
All I can say is we must speak out for our loved ones, especially if it seems like it doesn't align with a plan that had previously been settled by another team member.
Also, did you put all the symptoms together? Ask the mom her concerns and relay them to the appropriate members of the team. This is what you can do as the nurse, as the clinician, as the physician.
And our loved ones can be advocates, right? It's okay to ask questions. If they don't like you asking questions, that's a concern.
It's okay to ask questions. The patient and their healthcare proxy has the right to do so, and it's actually important that the patient is the most important member of the team, and especially when it's a child, their caregiver is the surrogate for them, right? They're the ones who will speak for them.
Sorrel, her mom, is an amazing woman who did something very brave and noble after all of this occurred. She started an organization, the Josie King Foundation. She speaks at healthcare facilities about how to prevent these tragedies. She's spoken all over.
She speaks at Grand Rounds, at high-level leadership meetings, she speaks to families, patient advocates, doctors, nurses.
We can learn a lot from her, and from our patients, and their loved ones. They are experts on themselves.
Josie's story is the name of a book written by Sorrel King, the mother of Josie. If you want to learn more about this, you can also go to josieking.org.
There is a lot of information available online. She has been featured on various news programs in the media circuit, and I think it's such a testament to her daughter that she goes out and tries to prevent this from happening to anybody else. What a healthy way of dealing with your grief.
Her story has reached all over and has been used as teachable moment for healthcare providers all over the world. There is a DVD about the story, and it can also be streamed for a fee on the website.
And I thank you for listening. It's a story that I share with all my students, and I think we can all learn from as clinicians and as patients and loved ones. Take a listen.
Take a moment. Why are they asking this question? They're not just trying to be annoying.
On the next episode, we'll talk about another case, a case of a nurse who experienced a tragic circumstance after making an error related to patient care and the aftermath of that era.
This was Shawna Butler, nurse attorney. Thank you for listening, and I will catch you on the next one. Thank you.
Thank you so much for listening to the Medical Legal Podcast. If you enjoyed the show, please take a moment to leave a review on Apple Podcasts. It really helps more listeners find the show.
And if you know someone who would find these stories compelling and interesting, share the podcast with them. Until next time, stay curious, stay informed, and take care. And to all my healthcare clinician listeners, always remember to practice in the best interests of every single patient.
Thank you.
