Just as important as the classroom content and Capitol Hill trip, is the ability to network with professionals from the nation’s leading hospitals and healthcare facilities. Our group this year represented the whole gamut of healthcare professionals from facilities around the country. Attendees included physicians, surgeons, R.N.s, surgical directors, supply chain coordinators, materials managers, value analysis and contracting professionals.

The program, carefully crafted by the Georgetown School of Nursing and Health Studies at the McDonough School of Business, is also underwritten by an educational grant from Kimberly-Clark. Institute organizers George Liebensfeld from the McDonough School of Business and Dr. Pat Cloonan, School of Nursing & Health Studies, work closely with Sandy Buhler, manager of professional relations from Kimberly-Clark, on developing a relevant and stimulating program. The program content changes yearly to reflect current issues in healthcare.

This year the program opened with a session that brought us down the difficult pathway of how hospitals handle mistakes – and how they may learn from them. Dr. George Dover, director of the Johns Hopkins Children’s Center, told us how his institution had the terrible misfortune of contributing to the death of 18-month-old Josie King, due to a medication error under their care. He led us through the discovery process the hospital had taken to find out what went wrong, and why. He emphasized that to develop a culture of safety in your hospital, it is necessary to identify potential errors before they harm patients. It was a powerful lesson that taught us that a better safety culture does not put responsibility on an individual, but on the system and all the members of it.

In this particular case, there had been many breakdowns in communication surrounding treatments, products and supplies used on the child, plus scheduling issues and missed safety procedures. Johns Hopkins worked with the Josie King foundation, founded by Josie’s parents, to develop a program that emphasized listening and communicating. At one point, Josie’s mom had questioned a drug therapy about to be administered but was assured by the nurse that it was okay. It wasn’t. The hospital has now implemented a policy to ‘stop and listen’ to the patient/family and they’ve hired 3 FTE Hospitalists to assist.

The open group discussion after Dr. Dover spoke clearly showed that there is a widespread communication problem in healthcare facilities, especially around product change and introduction. Many shared stories about near-misses at their hospitals caused because a bottle or package was redesigned and could now be easily mistaken for another product that could cause harm. There was also a somewhat humorous but costly tale of an expensive product being rejected and thrown out during a surgery because the surgeon thought the product had gone bad but discovered much later that the manufacturer had changed the applicator color. Discussions ensued about how best to implement a known product change or variation. This included sitting down with their vendors so they could be part of the solution to eliminate confusion on product selection. Ideas included vendors speaking to clinicians before they change product colors, labels and containers; and looking at what else is being stocked in the department from other vendors. When a product does change, they emphasized how important it is to educate all staff (materials management and clinicians), that a selected product may have a package, color or design change before it shows up on their floor or at the bedside.

If we weren’t convinced of the importance of communication after our first class, the next session was led by Sorrel King, Josie’s mother, and founder of the Josie King Foundation. The foundation is dedicated to preventing death or harm from medical errors. She took us through Josie’s last days and the domino effect of missed communication that caused the final devastating outcome. The foundation has worked with Johns Hopkins on improving communication and they have developed a Care Journal that is given to every patient. The journal has pages that prompt patients and their family to write down the names of their physicians, nurses, drugs, treatment plans, diet instructions, even where they parked their car - and encourages them to write down any other questions so when the caregiver comes in, they are ready to ask and can write down the answers. (To learn more visit www.josieking.org.)

Sorrel spoke of feeling powerless and inadequate in telling the nurses that something was very wrong with her daughter and yet still being unable to get help. The foundation developed a program called Condition H to help address the needs of the patient and family, for example, when they are unable to get the attention of a healthcare provider in an emergency situation. It provides patients and families an avenue to call for immediate help when they feel they are not receiving adequate medical attention; or if they otherwise become concerned with what is happening.

Especially since we’re working in healthcare, or in my case following it closely, I think we all may think that a ‘Josie’ situation couldn’t happen to us or our families because we know what to look for and guard against. My youngest daughter had surgery last summer at Johns Hopkins. Everything appeared to be routine when I was called into the surgical recovery unit by a nurse who explained that my daughter was having an allergic reaction to the pain killer they had administered in her I.V. Her condition had stabilized, but she asked if I would stay with her in this very busy recovery area where she needed to remain several more hours. Later we were transferred to another area where a different nurse took over her care. The long and the short of the story is that the new nurse did everything right from what I could see. She scanned the patient I.D. code, she scanned the new I.V. bag and she was ready to hook it up when I asked what the medication was. When she told me, I explained that my daughter had just had an allergic reaction to the same medicine. She immediately stopped. She excused herself and came back 5 minutes later explaining that the allergic reaction notification had not made it to the pharmacist before they had sent down my daughter’s next infusion. I knew we had just averted a medication error that had the potential to harm my daughter because the nurse had ‘stopped and listened’. I told Sorrel that story and thanked her for making what I truly believe, was a difference in my daughter’s care.