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Patient Safety-The Josie King Story PowerPoint Presentation

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Description : About the Josie King Story and how it changed healthcare

Tags : healthcare,patient safety,josie king story

Published on : Aug 13, 2022 | Views : 3441 | Downloads : 0

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Slide 1-

Josie King Root Cause Analysis
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Healthcare Errors Overall Lack of Care Communication Lack of Assessment Josie King’s Health Care Errors Did not consider parents concerns Obvious signs of dehydration Rights of medication administration Interdisciplinary communication Would not listen to parent Lack of follow up Not really looking at the medical problems Multiple handoffs
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18 months old Admitted to the hospital for 2nd degree burns While in PICU she was NPO and on IV fluids Received narcotics for burn pain Was getting better so moved to intermediate care level Removed PICC line but did not remove NPO status Kept giving narcotics anytime she fussed or moved What Happened
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Two days before expected to go home, Sorrel arrived at hospital, found Josie unresponsive Doctors called, gave two doses of Narcan for overdose Verbally ordered D/C of narcotics and granted Sorrel’s request to give Josie something to drink Nurse came and wanted to give injection of methadone Sorrel told nurse doctor said no more narcotics Nurse said orders changed and gave injection Josie went into cardiac arrest Josie was transferred back to PICU but was brain dead
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Communication Would not listen to parent Interdisciplinary communication Rights of medication administration
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Lack of assessment Obvious signs of dehydration Did not consider parents concerns
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Overall lack of care Lack of follow up Not looking at medical problems Multiple Handoffs
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Core Competencies Developed to give guidelines in different categories, so every nurse would know what is expected of them.
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Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. QUALITY IMPROVEMENT (QI)
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Minimizes risk of harm to patients and providers through both system effectiveness and individual performance. Safety
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Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. TEAMWORK AND COLLABORATION
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Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. INFORMATICS
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Throughout the Josie King story there are so many times the healthcare workers did not live up to the core competencies. Now, lets go back to the story to see where the healthcare workers went wrong.
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18 months old Admitted to the hospital for 2nd degree burns While in PICU she was NPO and on IV fluids Received narcotics for burn pain Was getting better so moved to intermediate care level Removed PICC line but did not remove NPO status – Lack of charting this was a huge contributing factor to Josie’s dehydration! Kept giving narcotics anytime she fussed or moved – the nurses should have assessed and charted what they assessed and maybe they would not have given so much narcotics! What Happened
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Two days before expected to go home, Sorrel arrived at hospital, found Josie unresponsive. When was she last checked on, what were her vital signs? When was she given narcotics last, and was she assessed before giving her the narcotics? Doctors called, gave two doses of Narcan for overdose. Very serious to have to give Narcan to reverse effects on narcotics, extra care should have been taken to document this so next shift would know. Verbally ordered D/C of narcotics and granted Sorrel’s request to give Josie something to drink. Why didn’t the doctor assess the patient when major complication with any burn patient is dehydration?
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Nurse came and wanted to give injection of methadone Sorrel told nurse doctor said no more narcotics methadone. – Nurse should have listened to Josie’s mom and at least called the doctor to see if he really d/c the narcotics. Nurse said orders changed and gave. Nurse should have used the rights of medication administration, and called the doctor if necessary to verify the latest order. Josie went into cardiac arrest. – This could have been completely preventable if all the healthcare workers followed the core competencies. Josie was transferred back to PICU but was brain dead.
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“If you don’t chart it, it didn’t happen!” And in this case it even goes so far as “since you didn’t chart it won’t happen!”
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Implications It is irresponsible to give pain medication unless you assess the patient. It is irresponsible to give any medications unless you follow the 5 rights of medication administration. You are obligated to listen to your patient/family our you violate autonomy.
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Courses of action The nurse should assess their patient before doing anything! The nurse should always use the rights of medication administration. The nurse should put aside all personal judgement and bias. The nurse should listen to the patient/family, which is part of autonomy.
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Culture I think the hospital staff did not listen to Josie’s mother because they felt she was just being an overprotective and overbearing mother. I think they also felt she was a rich lady that was used to bossing everyone around so they discounted what she was saying. Healthcare professionals should always put their personal judgement and bias aside to give the best care to everyone.
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References Amer, K. (2013). Quality and Safety for Transformational Nursing. Boston, MA: Pearson. Faruk Medical City. (2014, November 17). Training on FMC Patient Safety Approach. Retrieved from Faruk Medical City: https://www.farukmedicalcity.com/Details.fmc/Hawal/41 Finkelman, A., & C, K. (2012). Learning IOM: Implications of the Institute of Medicine Reports for Nursing Education. Silver Spring, Maryland: Nursesbooks.org. Josie King Foundation. (2016). Home. Retrieved April 2, 2017, from Josie King Foundation: http://josieking.org/home/ Nitkin, K., & Broadhead, L. (2016, January 8). No Room for Error. Retrieved April 1, 2017, from Johns Hopkins Medicine: http://www.hopkinsmedicine.org/news/articles/no-room-for-error QSEN Institute. (2014). QSEN Competencies. Retrieved April 2, 2017, from QSEN Institute: http://qsen.org/competencies/pre-licensure-ksas/ Quality and Safety Education in Nursing (QSEN). (2013, September 24). The Josie King Story Clip for QSEN. Retrieved from YouTube: https://www.youtube.com/watch?v=JeVcXhvPvbU&feature=youtu.be
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