JKF Journal

Josie King Foundation now on Twitter

2009-07-01T10:59:00.002-04:00

Hello everybody-

I'm happy to report that the Josie King Foundation is now on Twitter! You can follow us at www.twitter.com/jkfaw.

We're looking forward to connecting with the patient safety community here.

How do you use Twitter?

-Andrea

More Great Advice from Nurses

2009-04-16T11:36:00.004-04:00

Hello again-

The rejuvenating tips from nurses on how to cope with work-related stress keep rolling in. I just wanted to share the latest bits of advice with you.

Keep 'em coming! Keep spreading the word about this project!

-Sorrel

"I de-stress by dancing at least once or twice a week. I love dancing - it is something that helps keep me sane and gives me something to look forward to outside of work. One tip for work stress: Don't take things personally. If a patient/colleague/family member/MD snaps at you, it's not you - they are stressed out too. I find laughing defuses the situation - it helps them relax. It also prevents me from getting angry - which would just escalate the situation. Yeah, don't take things personally is the best advice I've been given. I also vent to my nursing colleagues - it helps to know that other people are sharing your pain." - C. Rae

"Take a moment everyday to reflect on what went well, what didn't go so well, and what you can do better tomorrow.

Always take a moment to take a deep breath when the world is moving quickly by you and you can't keep up. Who knows your speed might be what everyone should be moving at throughout the day.

Baking fresh treats for your co-workers is the best medicine and always makes a nurse's day brighter." - Sheryl C., RN, MSN, Washington, DC

"I find that in order to care well for others, I must first take care of myself. Without my health, I wouldn't have the strength to perform the hard work nursing requires. Daily exercise and good nutrition are essential to helping me cope with stress. I love group fitness classes, weightlifting, and 'clean' eating!

I also set aside one night a week to relax and have a date night with my husband." - Kathryn A., BSN, RN, South Lyon, MI

"As a NP I try to remember to always thank everyone for helping me to help my patients. It really is a group effort. And thanking people is a great way to defuse stress as it makes people feel appreciated. Surprising the staff every once in awhile with cookies or another treat goes a long way to making people feel appreciated. Praying with patients and staff is a great way to lessen stress." - Kimberly B., MSN, CRNP, Pittsburgh, PA

"I know that it sounds sappy but...I try to appreciate all the good things, my family, my health, my job, etc. I don't want to be in the position (like some of my patients and families) of having regrets (the could of, should have syndrome) in life. I am not waiting for retirement to care for myself, to tell my husband or children that I love them, or to just be in the moment. Life will probably always be too short but my glass is more than 1/2 full." - Maureen

"I find good friends to be the best stress relief. I love my coworkers and we go out regularly to debrief about work and personal lives. I also value my non-nurse friends that I don't talk about work with. They help me remember there is more to life." - Anonymous

"We go through so much each day. I have been a nurse for many years, most in the Baltimore area. What really helps me is thinking about how the families and patients feel, particularly after losing a child. Sometimes we get so wrapped up in the technology and what we have to get done each shift. However, when I start feeling that way, I think, if this was my family, how would I feel and what can I do to make it better. That is how I cope." - Joanne M., RN, MSN, NE-BC, FABC, Newark, DE

Nursing Project Update

2009-03-28T04:30:00.007-04:00

Thank you to all of the nurses who sent us their words of wisdom on how they deal with work-related stress. We are compiling these tips into a toolkit specifically for nurses. This project is under development.

Below this note are some of the great comments we have received. Please take a look. I hope you find them as helpful and inspirational as I do. Please, please keep the comments coming and spread the word to other nurses who many have a helpful tip they want to share. Remember, you can post your advice directly on the blog, or you can send an email to nursing@josieking.org.

Thanks, too, to everybody who has helped us spread the word about this project. Your efforts are really making a difference!

-Sorrel

"Having spent most of my nursing career working in Adult ICU, I find that staying 'grounded' literally helps keep me sane! I like to spend time outdoors - whether trout fishing on a beautiful stream or lake, working in my yard or garden, or just taking a walk really helps puts things in perspective. I especially find sharing time and talking with my family helps maintain balance." - Tamma

"I think my staff is just the greatest. When our work life becomes very challenging I like to have lunch with the staff and catch up on what is happening in their home life. It does help maintain balance. We have mini "Lunch and Learns"; we lunch and learn that life does not have to be all serious." - Mary Ann, Pittsburgh, PA

"One of the things that I feel has the most impact on helping nurses to cope with the everyday stress is the fact that we are a team of professionals and when push comes to shove, stand together and help each other - basically we are each other's counselors. We openly discuss our feelings with our co-workers and cry together while giving each other hugs and letting each other know we are here and that we all understand what each other is going through. That kind of support is not felt in many other professions. We are a team of support and care for all!" - Tracy N., RN, BSN, MSN, Pittsburgh, PA

"Learning to de-stress, by spending time with my daughters or just me by reading a good book or going for a run with my dog. In my dream world every healthcare facility would have a gym and a massage parlor to help encourage all healthcare workers to take a moment to de-stress so we can think clearly." - Kimberley S., RN, Ontario, Canada

"I try to look for the humor in an otherwise difficult situation, to make myself laugh and others laugh, and to remind us all to not take ourselves TOO seriously. Laughter IS the best medicine and a unifying force in the midst of stress." - Sue

"I'm an optimist and try to maintain that optimism while working in a 'negative' or stressful environment. I like little quotes that I can hold onto. Sir Winston Leonard Spenser Churchill states, 'A pessimist sees the difficulties in every opportunity, an optimist sees the opportunity in every difficulty.' Thoughts like Churchill's keep me going. Here is another one: 'In order to succeed, your desire for success should be greater than your fear of failure,' from Bill Cosby." - Laura S., Lewes, DE

"I love to sew- especially baby quilts or crafts. While I'm sewing, I'm thinking about the new baby- and am always amazed by the miracle of new life and I know I have the opportunity to touch 'life' while I work. I am filled with wonder!" - Anonymous

"As a pediatric nurse, some days are definitely better than others. When the stress seems like it has taken over my life some strategies I use to cope include; having a good hearty belly laugh in the company of good friends, taking a trip to the playroom for some BINGO with the kids during a break, and remembering to step back for a minute to remember WHY I am a nurse and what my purpose is." - Alicia

"I recently started beading and I love to see what my imagination can create. I also have done scrapbooking for many years. I love to recall the memories of the event. I have recently been asked to teach scrapbooking to middle school age children who attend after school activities programs." - Lori

"I started exercising. Now to burn off stress, I run. In fact, I am running my first 5k this spring. I am also a bit (45 lbs) lighter, which is great, too. I feel so much better now that I have consciously taken my stressors off of me." - Elizabeth, Michigan

"Exercise always makes me feel best - I love riding my bicycle and get together with a co-worker that lives close by. We'll get together and chat and ride at the same time. I belong to a hiking/biking group. If I can get to a hike or ride once a week, I'm happy. The rest of the time is spent walking my dog when I have time to get out." - Dorothee K., Pittsburgh, PA

"I think stress relief depends on the energy needed to be expelled or reversed.

When I need to de-stress and calm down, walks in the forest and on the beach of Lake Michigan can be the best (especially with the dog). Other calming activities have included yoga, reading a novel by the fireplace, and cooking with family/friends.

The other spectrum, of energy "release" needs, can be best met by a workout at the gym, working in the yard, cleaning the car or the garage, and my favorite of all, is going out after work with a fun group of friends for munchies and cocktails (try to do that every couple months!)." - Todd K., RN, Holland, MI

"As a pediatric nurse working in ICU and the Peds ER for over 25 years I have seen more than a lifetime's share of tragedy and sadness when children are severely injured or killed. I have found peace in the ability to return to work to face another day only through the faith I have in God. I try to pray every day. I especially pray during a code - for the doctors and nurses administering care to the child, and for the parents. I found taking a walk or a drive and being quiet with God allows him to minister to my heart and heal me." - Ann D., RN, Copiague, NY

"My faith has carried my through my nursing career for 30 years and it has never failed me. Surrounding myself with my family and a few close friends has also been very important in coping." - Sandy

"I cope by listening to those who trust me enough to share their pain. Just by having someone open their heart to share the pure emotion, all of my stress seems to melt, and I find myself feeling very thankful and at peace with my life." - Anonymous

"Personally, I make sure I stay in contact with those I love the most during the week. My children and grandchildren all live out of town. A phone call to any one of my grandchildren always lifts my spirits. Their energy is contagious, even over the phone." - Kathy, Harper University Hospital

"I take my dog on a long walk and then once home drink a large glass of ice water to flush out any remaining stress hormones." - Shelley, RN, Pittsburgh, PA

Needed: Advice from Nurses

2009-03-10T13:19:00.008-04:00

I need your help. We've been struggling with something here at the Josie King Foundation. Here's the deal: we are creating a toolkit for nurses, something that will help nurses cope with the stresses of the job, something that will make their days a little better, something that will let them know how much we appreciate them. I know lots and lots of nurses. I've seen them at work in hospitals around the country. I'd like to think that I sort of have a notion as to what it must be like to be a nurse, but the truth of the matter is- I don't REALLY know.

So, I am asking all of you wonderful nurses to help. Here's what I'm looking for: quick tips on how to cope with the challenges of being a nurse. What do you do that helps you do your job well? What have you discovered that helps you deal with stress? It could be anything like:

"Once a week I buy fresh flowers to put in the nurses' snack room." - Sandy K., RN, Grand Rapids, MI

"When I come home after a long day on the job, I like to bake cookies with my eight-year-old." - Sue S., RN, BSN, Tampa, FL

"I just started walking for forty minutes every day with my neighbor. It really helps clear my head, and my jeans fit a little better." - Tamara M., RN, Houston, TX

Please post your tried and true tips below. You can also email your tips to nursing@josieking.org. We want to collect and share your great ideas with other nurses. If you would like to, please include your city and state, too.

I'll be sure to share updates on this project as it progresses, but right now we need as many tips as possible from nurses. Spread the word to your nursing friends and colleagues, and have them post their tips, too.

Thanks so much for your help with this, and for all of your hard work with patients,

Sorrel

Patient Safety Week

2009-03-09T12:46:00.005-04:00

It's Patient Safety Week- a time to reflect on all of the great patient safety projects and initiatives that have been under way. So many people have done so much to make our hospitals safer and for that I am forever grateful. But this is also a week to look ahead towards an even safer, better health care system. From what I can see, we have come a long way, but the journey is not over yet. There is work to be done.

I've heard from nurses and doctors all around the country who are planning on commemorating Patient Safety Week. There will be speeches announcing new safety programs, and ceremonies honoring caregivers who have done remarkable safety work. Patient safety is front and center, and I am excited about that.

Let's stay invigorated. A few quick hopes of mine:

If you are a caregiver, keep focusing on improving how you communicate with your co-workers and patients. Even if your team communicates well, the nature of team work is one of continual change, and it helps to check in every now and then to make sure everything is still working well.

If you are a student, keep learning about patient safety and preventing medical errors. Ask your professor or mentor about the changes they have seen with regard to medical errors since they started practicing.

If you are a patient or family member, thank your health care team for incorporating patient safety techniques into their daily routine.

I'll be commemorating Patient Safety Week with a few groups around the country this week. I hope that everybody is able to support Patient Safety Week in a way that is helpful and meaningful for them.

Keep up the good work!

-Sorrel

Update: IHI On Call Transcript and Audio Download Now Available

2009-03-04T05:07:00.003-05:00

Hi everybody-

Just wanted to spread the word that the transcript and audio download of Sorrel's IHI On Call session are now available at IHI's Open School website.

We hope that you enjoy the conversation. Feel free to comment on the session here, or at IHI's Open School blog.

Thanks,

Andrea

IHI On Call: Talking with Nursing and Medical Students

2009-02-26T08:13:00.004-05:00

The first time that I ever spoke to a room full of medical students was a few years ago at Johns Hopkins. I told them Josie's story and at the end of the talk I asked them if they had ever head of the Institute of Medicine's report "To Err is Human". No one raised their hand. I remember feeling shocked that these students- who were taught how to cure diseases, deliver babies and mend broken bones- were not being told about one of the leading causes of death in our country- medical errors. The more medical and nursing students to whom I talked, the more I realized that it was indeed a rarely discussed topic. I found this frustrating and confusing. Since then I have tried to talk to as many medical and nursing students as I can. These young minds are the next generation, and if I could make a tiny difference in how they would care for their patients by sharing Josie's story then I was going to do it.

I am grateful to the Institute for Healthcare Improvement (IHI) for creating the Open School (www.ihi.org/openschool). The Open School is a great resource for medical and nursing students to round out their patient safety education. They offer free courses in patient safety and quality improvement, sponsor essay contests, and host safety conferences for students of the health professions. Each month the Open School offers an On Call teleconference lecture, in which a guest speaking talks about a topic related to patient safety. Students from all over the country listen in and learn. I don't believe anything can take the place of a classroom with a professor, however this may be the next best thing.

On Tuesday- with the help of modern technology- I sat at my desk in my home in Baltimore and had the honor of talking to a few hundred students from around the country. The session was called "Channeling Grief into Action". Simon Mathews, a medical student at Johns Hopkins, moderated the hour-long session. I shared Josie's story. I explained that Josie didn't die because of one misplaced decimal point, because of one doctor or nurse. She died because of a lack of communication. After I spoke, Simon opened the lines to take questions from callers. I loved hearing from the students and I could tell that they had been moved.

For me it had been an hour well spent. It was my chance to make an impression on these brilliant minds that will take healthcare into the future. It was my chance to remind them of the importance of good communication and the need to create a culture in which reporting errors is considered heroic; a culture where doctors and nurses work as a team to prevent medical errors; a culture where the patient is heard and when a mother says, "Something is not right..." she is listened to. I hope I succeeded in delivering that message.

Thank you to IHI for realizing the importance of getting this information to students. Thank you Deepa Ranganathan for pulling the program together, and thank you Simon Mathews for being a great moderator.

For more information, check out the links below:

-An audio recording and a transcript of the session will be available at www.ihi.org/openschool at the end of the month. This link is also the gateway to all of the information about IHI's Open School.

-IHI's Open School blog (www.ihiopenschool.blogspot.com) has an open conversation about the session where you can post comments/questions. I'll be checking in on the comments and responding to them.

-Want to take IHI's educational programming wherever you go for free? You can subscribe to their informative podcasts at the Apple iTunes Store. Just go to the iTunes Store, search for "Institute for Healthcare Improvement" and click "Subscribe" to download IHI's podcasts.

Book News

2009-02-04T12:00:00.007-05:00

When Josie was first in the hospital, I kept a journal. It helped me remember everything that was happening, everything we had to do. It helped me release some of the stress. When she died I continued to write. I wrote and I wrote and I wrote. I had to get my sadness, my anger out. It was one of the things that really helped me.

As I ventured into the health care industry, I continued to write off and on. One day I realized that I had what looked to be a book in the making and so I showed it to a few people. They told me to find a book agent, so I did. My agent told me I could get a book deal, and I did. Two years ago I signed with Grove/Atlantic, a publisher in New York. Since then I have been working on the book pretty much full time.

The book is called Josie's Story. It is about how our family once was. It is about Josie's death and how we struggled to survive. It is about making the decision to either let the grief and anger destroy me or do something positive, something for Josie. It is about the search for religion, the search for understanding what it means to forgive and the search for the reason why. The book is about my journey into a world I knew nothing about, the health care industry. It is about the wonderful doctors, nurses and other health care providers I have met along the way and the amazing hospitals that have invited me - in my small way - to help them become safer. But most importantly the book is about all of the wonderful things that have come from Josie's death. Josie's Story will be in bookstores in September 2009.

I continue to accept speaking invitations. Starting in early September, we will be able to have book signings after the speeches. If you are interested in learning more about speeches and book signings, click here. Of course, you can always email any questions about speaking requests to speaking@josieking.org. We will get right back to you.

As we get closer to our publishing date we will have more details to share.

One final note- a portion of the proceeds from the book will go to support the Josie King Foundation.

Thanks- as always- for your interest and support.

"Questions Patients Need to Ask"

2009-02-04T10:53:00.003-05:00

There is a great new book out there for patients and their families. It is called Questions Patients Need to Ask. Dr. David Shulkin, CEO of Beth Israel Medical Center in New York City, wrote it with the hopes that it would help patients and their families get safe care and be as informed as possible when in the hospital. Dr. Shulkin has been on the front lines of the patient safety movement for years now, and is truly passionate about patient safety.

It's important to ask questions when in the hospital, or in any health care setting. We developed our Care Journal with that very thought in mind. Dr. Shulkin's book is a great tool for empowering patients and their families. His book is informative and a must-read for anyone who is going into the hospital or who knows someone who is.

For more information, visit Dr. Shulkin's website at www.questionspatientsask.com.

Thank you, LeanBlog!

2009-01-19T09:53:00.003-05:00

Happy New Year!

The charity auction organized by Lean Hospitals author and LeanBlog editor Mark Graban has ended. Thanks to the winner, whose support will help us continue our grassroots patient safety work in 2009. Of course, thanks to Mark for his time and great idea!

We wish you a healthy, safe 2009.

Charity Online Auction to Benefit JKF

2008-12-10T15:05:00.006-05:00

Thanks to the generosity of Mark Graban, the Josie King Foundation is the charity beneficiary of an online auction.

Mark Graban is a quality consultant who recently wrote Lean Hospitals, a book that applies the "lean" techniques of quality improvement and employee satisfaction to the healthcare setting. Mark is also the founder of LeanBlog and LeanPodcast.

The item for auction is a 4-CD podcast of Mark speaking with lean expert Norman Bodek and one of Mr. Bodek's books, autographed by the author himself.

Please check out Mark's blog and consider making a bid to support the Josie King Foundation. The auction ends Friday, December 19th.

Thanks again, Mark!

Josie King Foundation and the Johns Hopkins Hospital Department of Nursing Patient Safety Heroes

2008-09-25T13:35:00.012-04:00

On Wednesday the Josie King Foundation and the Johns Hopkins Hospital Department of Nursing recognized nine nurses, one clinical technician and one support associate for their work in patient safety at Hopkins Hospital. These professionals were nominated by peers in their unit for their outstanding work and are true patient safety heroes. I'd like to introduce them:

Maxine Bell-Trusty, Support Associate - Neurosciences

Maxine has taken a special interest in preventing hospital-acquired infections. She is what the literature calls a "positive deviant"- someone who does the right thing and is an agent for good. She single handedly advocated for two new practices in the Neuro Critical Care Unit: 1) using a fresh rag to clean each separate piece of equipment in isolation rooms and 2) requiring terminal cleaning of the patient's room once they were taken out of isolation. We know from lab cultures that Bell-Trusty has reduced the prevalence of multi-drug resistant organisms on her unit. While we often worry that the "bugs" are winning, Maxine has won the battle in her unit.

Kelly Creighton, BS, RN - Medicine

After a serious event involving a monitor alarm in 2006, Kelly's unit set out to improve the safety of patients on physiologic monitors. They determined that 27,000 alarms were set off on their 15-bed unit every 24 hours- that's one alarm every three seconds. Creighton worked with her committee and the Clinical Engineering team to improve the situation, reducing "nuisance alarms" by 26%. Kelly literally took the noise out of the system, so that nurses could respond more quickly to patients in trouble.

Catriona Henderson, RN - Oncology

As part of her night shift routine as a charge nurse, Cat reviews all lab values for the patients on

her unit. She found inexplicable changes in a number of patients' sodium values. So she followed her instincts (and her intellect) that something was wrong with the laboratory findings being reported in a large series of patients. Working with the lab, an investigation found that more than forty patients in the Cancer Center had incorrect sodium calculations made. But thanks to Henderson's astute observation and quick action, only one patient was treated for the incorrect results (without any adverse effects).

Vicki Jackson, Clinical Technician - Emergency Department

Vicki championed doing "re-vitals"- that is reassessing patients in the emergency department. In the past two years, she identified significant changes in patients. One was having a heart attack, and the other a stroke. Because of Vicki, these two patients received the required treatment from the heart attack team and the brain attack team earlier than they would have. When minutes count, Jackson's vigilance was life-saving.

Sara Nakamoto, RN - Gynecology and Obstetrics

Sara is a new graduate who joined Hopkins in March 2008 and she has already demonstrated an
aptitude for promoting the safety and well-being of the very ill patients under her care. For
example, Nakamoto discovered that a pre-mixed IV solution had one medication label applied
over another label. The IV bag actually contained the solution noted on the hidden label, and this
drug was contraindicated for the patient. Nakamoto's patient had impaired renal funcation with
only one kidney, and could have suffered significant complications had the drug been
administered. For this patient, Sara was a hero.

Liza Raymundo, BSN, RN - Ophthalmology

Working the tail end of the night shift, Liza was preparing a surgical patient as the first case for the operating room one morning. The patient complained of not feeling well. Liza assessed the patient, whom she identified as having symptoms indicative of an impending stroke. She organized the ophthalmology team and facilitated the patient's transfer to the Emergency Department where the required treatment was rendered in a timely fashion. Her quick assessment and critical thinking provided an immediate intervention so that the patient with an impending stroke was managed in a controlled environment.

Kathleen (Kathy) Robertson, MSN, RN - Surgery

The Hospital has been implementing an electronic provider order-entry system requiring all physicians to enter their orders online, and all nurses to document administration of medications in an electronic record. While the system was designed to be safer than paper-and-pencil versions, it was not fail safe. Robertson orchestrated the collaboration between physicians and nurses that was needed to develop the order sets, and implemented the change across the Department of Surgery. Many safety issues have arisen during this process. Robertson monitors these, and drives safety issues to the top of the priority list for system modifications. While many of our safety heroes have prevented individual patients from being harmed, Robertson is working to make the whole system safer.

Gloria Scott, BSN, RN - Pediatrics

On a unit where children and adolescents are treated for psychiatric illnesses that cannot be
managed safely out of the hospital, security is a critical concern. Gloria Scott worked with the
Pediatric Safety Team to add a security officer to the unit. The lay security officer could maintain
a presence at the front door; identify visitors to determine if they are authorized; check visitors'
belongings; and lock away valuable or unacceptable items. However, the security officer was also
needed to help with patients in a clinically appropriate manner. Scott explained the unit to the
officer, taught the officer how to handle patients, and otherwise implement this new role.
Because of Scott, the environment is secure and the patients are safer.

Melinda Walker, RN - Psychiatry

The stories about Melinda are legion. In summary, she "sees" problems and fixes them. To give
one example, Walker recognized a set of safety concerns in the electroconvulsive therapy (ECT)
suite. She subsequently prepared a 30-minute educational program covering how to prepare
patients for ECT; transport anesthetized patients safely; and maintain a smooth flow of patients
through the recovery phase. Her educational program has been incorporated into the annual
review that all RNs must complete. Walker is a safety hero for preventing harm from befalling
her patients.

As you can see, their work covers the gamut from actually saving a life to improving the systems

so that errors can be caught before it is too late. Each had a different story to tell, but one thing

that they all had in common was that in going the extra mile, in going beyond the call of duty

they often faced push-back. They each persevered and fought for what they truly believed needed

fixing. Some of these system changes have been adopted in other units, some will be published

in medical journals, and I believe that all of them will make care safer for the patients of Johns

Hopkins.

It was an honor to acknowledge the work that they did- not to receive awards- but because they

were simply compelled to do what they felt was right. I know that Karen Haller, Vice President

of Nursing and Patient Care Services at Hopkins, joins me in sincerely thanking them for their

commitment to patient safety.

(Thanks to Hopkins for providing the safety heroes' stories!)

Boston Part 2: Health Care's Holy Grail

2008-09-23T10:00:00.003-04:00

Energized from the previous night's meeting with the HCA folks, I took a cab to the John F. Kennedy Library to a conference put on by Blue Cross Blue Shield of Massachusetts (BCBSMA). The conference was titled "In Pursuit of Health Care's Holy Grail: The Quality Movement That is Transforming Health Care".

The conference room was beautiful with a wall of windows as the backdrop of the stage, overlooking pretty Dorchester Bay. The audience consisted of doctors, nurses, health care leaders and public policy people all from the state of Massachusetts. These people had come together to celebrate the movement and to more importantly be inspired to continue on in the improvement of health care delivery at their hospitals. The centerpiece of the event was Charlie Kenney's new book The Best Practice: How the New Quality Movement is Transforming Medicine.

The morning began with a welcome by Cleve Killingsworth, the Chairman and CEO of BCBSMA. It was apparent to me as I listened to him that he and his organization were committed to patient safety. It seemed that BCBSMA was going beyond the call of duty. BCBSMA isn't sitting in the back of the room, merely observing the quality movement, but its leaders are committed to leading the way and I am grateful for that.

After Cleve's opening remarks, I shared Josie's story and my thoughts on Charlie's great book. I recommend this book to anybody interested in learning more about the history of the patient safety movement that is truly changing health care for the better. I hope that the book can raise awareness on the reality of medical errors and inspire people to continue their work to improve patient safety or even to take up the cause.

I could go on and on about the interesting ideas of Charlie and other safety leaders like Don Berwick of IHI, Louise Liang of Kaiser Permanente, Uma Kotagal of Cincinnati Children's Hospital, and Goran Henriks of the Qulturum in Jonkoping, Sweden, but instead I'd like to send you to Paul Levy's blog "Running a Hospital". In addition to being the President and CEO of Beth Israel Deaconess Medical Center in Boston, Paul is an amazing blogger. He was at the conference, and has done an excellent job on writing about the days events. Take a peek.

Boston Part 1: The Grassroots of a First-of-Its-Kind Law

2008-09-22T14:19:00.005-04:00

I flew to Boston on Monday, September 16, for a conference put on by Blue Cross Blue Shield of Massachusetts, which was to be held the next morning. Earlier in the week Jim Conway from the Institute for Healthcare Improvement contacted me and told me about a group in Boston that was doing some interesting things in the patient safety advocacy vein. He suggested that we meet.

And so Monday night I had dinner with five people from Health Care for All (HCA). HCA is a Massachusetts-based non-profit organization that is working to- among other things- create greater quality health care throughout the state. You can read all about them on their website. HCA sponsors the Consumer Health Quality Council- a very active and renowned coalition of health care consumers who have been personally affected by medical errors. The Council was created in 2006 and currently has about 40 members who are doing some impressive things: sharing their medical error stories with the public, advocating for improved health care, and meeting with legislators to introduce health care improvements into law.

A recent success included their year and a half-long work in the development and signing of a groundbreaking state law that includes:

mandatory reporting of all hospital-acquired infections
mandatory reporting of all "never events"
creation of rapid response methods at all hospitals
creation of patient/family councils at hospitals.

This was an interesting group. I urge those of you reading this who want to make changes within your state to check them out.

I'll be back tomorrow with more from my trip to Boston, including the Blue Cross Blue Shield of Massachusetts' patient safety event.

"Don't think that you are more safe in a place just because they don't talk about their errors. "

2008-08-29T03:54:00.009-04:00

With Labor Day right around the corner, I'm catching up on some healthcare blog reading that I've missed out on while enjoying the summer. Earlier this month on "Running a Hospital" Beth Israel Deaconess Medical Center CEO Paul Levy discusses transparency in the patient safety realm. BIDMC took the bold step to report the incidence of preventable harm events on their very public website. You can take a look at the report here.

For each of the Joint Commission's preventable harm events, BIDMC lists the number of times such an event happened at the hospital within a quarter. Levy's discussion on the motivation and concerns surrounding such a public forum is insightful. The emphasis on reporting the raw number of harm events- and not obscuring them by reporting them as percentages of total patient population- shows a real understanding that patients are people whose lives are truly impacted by preventable errors.

It also sets up a clear standard of comparison; the goal is to have zero preventable events, and anything above zero signals continued room for improvement. What's the bottom line? Big thinking in a simple framework that patients, nurses, doctors and hospital administrators alike can use to chart progress and identify ways to change the status quo and improve patient safety.

The line from Levy's post that struck me the most is the quote used for the title of this post: "Don't think that you are more safe in a place just because they don't talk about their errors." I think this succinctly sums up an important aspect of patient safety today. For years, it was commonly assumed that there was an acceptable threshold for errors in medicine. Then came the realization that harm events could be prevented by analyzing and reworking broken systems. It's a huge change in philosophy, and the exciting part is that as patients and healthcare providers, we are all in the middle of a true zeitgeist shift. The language and tools to move medicine into a new, safer phase are right now being developed at a quick clip, and it will take some time and thought to figure out how we can best use these new resources to improve patient safety.

Surprising news about the incidence of harm events at one institution doesn't necessarily mean that a hospital isn't safe or actively trying to become safer; instead, it's a new way to bring healthcare providers and consumers on the same safety page.

Thanks,

Andrea

Condition H Networking

2008-07-22T08:29:00.006-04:00

Every now and then, I get emails from people who are in the middle of implementing Condition H, and would like to talk with other healthcare professionals who have participated in a Condition H implementation.

For example, here are some good questions we recently received from Wisconsin:

1) What barriers, if any, did you experience from physicians and staff when implementing Condition H? How did you overcome them?

2) How do the nurses and medical staff react when the family or patient calls Condition H? Were there any feelings of guilt (i.e., "I failed the patient") or resentment? What resources are available for staff to debrief after a Condition H call?

3) How many calls do you get from patients or families per month? How many have been appropriate vs. inappropriate?

4) How willing were the physicians to do this? If there were any negative attitudes, how were they overcome?

5) If you have both staff-activated rapid response teams and patient- and family-activated rapid response teams, are the teams the same or do you have unique teams for both?

Are there any Condition H veterans out there who would be open to talking to colleagues in the early stages of implementation?

If you are interested, I encourage you to post below or email me at awesol@josieking.org to volunteer.

I will also set up a discussion page on our forum "Connecting with Others". Click here to enter the forum.

Thanks,

Andrea

UPMC Releases Good News on Condition H

2008-07-21T10:35:00.007-04:00

Good news from Pittsburgh. UPMC is reporting results from the first two years of its implementation of Condition H, the patient- and family-activated rapid response team program that is gaining good traction in patient safety circles throughout the country.

From September 2005 to August 2007, there were 42 calls to Condition H. All of the calls were instigated by breakdowns in communication between caregivers and the patient or the patient's family. As the patient safety movement continues to make great strides and develop new techniques to prevent medical errors, it's clear that basic communication skills remain key resources for both caregivers and patients.

These and other successes are discussed in detail in the May/June 2008 issue of the Journal of Healthcare Quality.

As a Condition H partner, we at the Josie King Foundation are so proud of their success and hope that their impressive results inspire even more hospitals to implement Condition H. As a healthcare consumer, I'm relieved to know that more and more fellow patients have access to these rapid response teams.

Condition H consistently ranks among the top of the inquiries that we receive. It's encouraging to hear from so many institutions in varying stages of implementing patient- and family-activated rapid response teams of their own. For those of you who are associated with hospitals that have active programs, consider sharing any successes or lessons from your experience that could help your patient safety colleagues.

If you are in the early stages of planning, or are just considering starting a similar program at your institution, you can find helpful information on our website. Background material on Condition H is available here. This page also contains program support materials developed by UPMC for their program, like educational brochures and evaluation tools. These materials are all available for download, for you to learn from, amend and use at your institution. Big thanks to our friends at UPMC for sharing their good work with the community.

Please send us your questions and share your stories by leaving a comment below or emailing me at awesol@josieking.org.

Thanks, and more soon,

Andrea

JKF Blog 2.0

2008-07-14T13:47:00.004-04:00

Summer! It's time for baseball and barbecues and vacations, but here at the Josie King Foundation it's also time to refresh our blog. We want www.josieking.org to be a continually useful resource for you, filled with new, helpful information and various ways to connect to the patient safety community. To better serve your needs, we've decided to add a second blogger to the mix.

This is where I enter the picture.

My name is Andrea Wesol, and I've been working with Sorrel and Tony for almost four years now. It's been a true pleasure to help them grow the Foundation and expand the scope of the work done in Josie's name. It's also been rewarding to communicate with you- the patients, families and medical professionals who write to us. I am most often the first point of human contact that most people have with the Josie King Foundation, and it's a role that I enjoy tremendously. I'll still be the one responding to your inquiries and ideas about the DVD of Sorrel's speech, Care Journals, Condition H, etc., so keep those emails coming. I do look forward to having the new medium of the blog to interact with you and generate public discussions about the patient safety topics that make this work so interesting.

Fear not- Sorrel will still be contributing to the JKF Blog. For you sports fans out there, think of me as the play by play announcer, and Sorrel as providing color commentary.

You can expect to find more frequent blog posts, so please bookmark this site and come back regularly to check out or contribute to the conversations. I encourage you to leave comments and questions about the blog after each entry, and you can always email me on any patient safety topic at awesol@josieking.org.

More soon,

Andrea

With the Medical Students

2007-10-12T09:38:00.001-04:00

A few nights ago I spent the evening with 27 Post-Baccalaureate students from Johns Hopkins University. I had been asked by the director to join the students for dinner and then speak to them for an hour or so. I was to be joined by Rick Kidwell, who had been the lead attorney at Hopkins when Josie died and was now at UPMC, University of Pittsburgh Medical Center.

The Hopkins Post-Baccalaureate program is a year long program that prepares students for medical school. Hundreds of students from all over the country apply to this program, with only 42 acceptances for 27 positions. These students have earned their undergraduate degrees with an average of a 3.7 or above. More impressive than their high academic standings are the things they have done after college on the humanitarian level. Each one had an amazing story to tell. Some had spent time teaching in impoverished areas overseas. One spent a year with Dr. Paul Farmer, who is known throughout the world for his work and dedication in the poor towns of Haiti. Another student worked with the world renowned Dr. Benjamin Carson, a Hopkins pediatric neurosurgeon. One student worked as a teacher in the Mississippi Delta and then went on to teach children with AIDS in Africa. These life experiences shaped their young minds and led them to discover what it was that they truly wanted to become. Doctors. It is this dedication to public service, this humility and this selflessness that set these students apart from all others and landed them in the prestigious Hopkins Post-Bac program.

I always find it invigorating to be with medical students. They are so young and eager with bright minds that can be shaped. I can see the future in their eyes, and as I sat at my computer the day before and read all that they had accomplished and all that they had contributed to society and at such a young age, I knew that it was going to be a memorable evening.

Rick and I sat on folding chairs on stage and began our presentation. I started by sharing Josie's story. I broke it down as if it were a case study and watched them as they began to put the pieces together, realizing that a little girl had died at one of the best hospitals in the world, not because of a misdiagnosis or a medication error. It was something far simpler: communicaton, or rather, a lack of communication. I continued to talk about the importance of disclosure, and what it means to a family to be told the truth, to have questions answered and to know that the problem will be fixed. Rick shared the hospital's side of the story. He talked about how doctors and nurses are affected by medical errors. He told the students that when they become doctors, and if they make a mistake always to tell the family. "Don't worry about a potential lawsuit," he said. "That is the job of the risk manager." The discussion led to error reporting systems, family involved root-cause analysis and more. They asked interesting questions, and they shared their thoughts.

Soon these students will be in medical school. They will be inundated with Biology, Chemistry, Physiology. The importance of communication might not be woven into their curriculum. This was my chance to sink a story into their hearts and hope that when they become doctors that they will remember how to listen and communicate. These students are going places. These are the ones who are going to win Nobel prizes and find cures for our diseases. They are going to save lives. I am sure of it. I was honored to be with them I wish them all luck, and I thank them for listening.

It All Comes Back to Communication

2007-06-07T14:11:00.001-04:00

In the nearly five years that I have been participating in this patient safety movement, I have met thousands of wonderful healthcare providers. I have visited hospitals all over the country. I have sat and listened to dozens of patient safety conferences and grand rounds. I have learned big words like nosocomial infections.

Through it all I have told Josie's story and every step of the way I have tried my best to inspire caregivers to incorporate patient safety best practices into their everyday experience on the job. I have looked and listened, and have been amazed at all of the good I see, while also being confused as to why things can't happen faster and why 98,000 people still continue to die from medical errors every year.

The thing that really continues to amaze me is the communication issue. Josie died because people didn't listen. They didn't listen to me, and they didn't listen to each other. I can't tell you how many stories I have on my computer from families who have been affected by medical errors, and there always seems to be a common thread, "They didn't listen."

Correct me if I'm wrong. Doesn't the Joint Commission report that over 60% of all sentinel events are due to a breakdown in communication? I am not a doctor or a nurse. I am not at the bedside, and I am not an expert in the field of patient safety; however it seems to me that if people communicated better we'd all be safer. I believe in high tech solutions. It is where we are heading, but wouldn't we get more bang for our buck if we communicated better?

I was in Pennsylvania a few months ago at a wonderful hospital by the name Abington Memorial. I was presenting at their Grand Rounds. After the presentation, I was lucky enough to join them on their Patient Safety rounds. The team consisted of two nurses, a doctor, and a board member. I was struck by two things:

The first was the presence of the board member. There is a lot of talk these days about getting board members involved, especially when it comes to safety and quality. It was so great to see first hand a hospital that was doing just that.

The second thing that struck me- Every unit we went to, the patient safety officer would ask the nursing team on the floor a question:

"If you could have anything you wanted on your floor to keep patients safe what would it be?"

Each floor had variations on the same response:

"I wish we could get into the doctors' heads."
"I wish we were more like a team."
"I wish we communicated better."

That is what they wanted. They did not ask for fancy equipment or the latest in technology. They wanted to understand what the doctors were thinking. They wanted better communication between the nurses and the doctors. The thing that amazes me even more is that I hear this everywhere I go. Communication- and it is not just between the doctors and the nurses. It is between the patients, their families and those who are caring for them.

It seems so simple, but I am learning that changing behavior is not an easy thing to do. I don't know what it takes, maybe time, maybe another generation, hopefully not more deaths.

I will tell you one thing. The board member that day heard that message loud and clear and I bet she shared what she learned with her fellow board members, at least I hope she did.

Introducing the Care Journal

2007-05-29T14:00:00.001-04:00

Have you ever been a patient or had a loved one who was a patient in a hospital? Did you feel overwhelmed and scared? Was a lot of information thrown at you? I am guessing that your answers to the above might be yes. I know that I felt that way when Josie was in the hospital. I was in a new environment and I was scared out of my mind.

One thing I did that really helped was to write. I kept a journal. I kept track of everything from my parking space number to the names of the nurses on duty. I documented the medications she received and I wrote down questions and concerns I had for the doctor. Writing gave me a sense of control in a situation in which I had none. It helped me stay organized and on top of what was going on each day.

In my conversations with other patients and families over the years I have learned that they too often found comfort in writing. I decided that the Josie King Foundation needed to offer a journal that would help patients and their families manage their hospital stays. Each page would represent a day of health care, whether the patient is in the hospital or after they have been discharged. We call it the Care Journal.

It was time to take the Care Journal out for a spin in the healthcare industry. What I learned shocked me. I was having dinner with a wonderful group of nurses. I excitedly unveiled the Care Journal campaign and as I waited for them to tell me how great of an idea it was. All I saw were blank faces.

They told me what it felt like to them and their colleagues when they see a patient or family member writing. It makes them feel threatened. Healthcare providers think that patients are creating documentation so that they can later sue. However, they all agreed that when they or their loved one was in the hospital that, absolutely, the one thing they did was to write. I asked other healthcare providers if they felt threatened in the same way, and the majority of them did.

I had no idea that nurses and doctors felt this way. The last thing I wanted to do was to further alienate the nurses from the patients, but I felt so strongly that patients should have this tool. My nurse friends and I came up with the perfect solution. The Care Journal needed to come from the hospital. It needed to be a gift from the nurse to the patient or family member.

This made great sense. We could offer a handy tool AND we could help bridge the gap of mistrust between the healthcare provider and the patient. Now, instead of a nurse looking at a patient and feeling threatened that nurse can say, "Oh, I see you are writing in your Care Journal. That is great and don't forget to write down your questions for the doctor when he makes his rounds."

Right now, we're working on the final touches of the Care Journal. We expect to have them in one month. If you work at a hospital interested in partnering with the Josie King Foundation to distribute Care Journals to your patients, I will send your hospital however many you would like. You can write up a personal note to your patients telling them that you encourage them to partner with you in their care and attach it to the inside of the Journal. All I ask is that your organization make a donation to JKF. Just contact me and we'll get you started.

If you are a patient, the Journals will be available from our website in a few weeks. All the money from the Care Journal project will go back into this patient safety movement, funding great new ideas to improve the culture of healthcare.

I hope you like this project. Please email me at sking@josieking.org to learn how to partner with us, learn more about the Care Journal, or- very importantly- let me know your thoughts on the project.

Welcome to Our New Website

2007-05-24T15:23:00.002-04:00

Thanks for visiting us at the Josie King Foundation's new and improved home on the web. I encourage you explore the various areas of the site, and also to send us your opinions on the site. As we worked to create this website, we were guided by the hundreds and hundreds of e-mails that I have received from patients, families, doctors, nurses, hospital administrators, medical students, and nursing students.

These e-mails came from all corners of the world and covered an enormous range of thought and emotion, but all had one thing in common- a passionate interest in and commitment to improving patient safety. These e-mails come from people like me who have been affected by medical errors in one form or another and are looking for ways to make their hospital safer.

This new website responds to your needs. It is a place that provides help and information. A place where people can learn from experts in the field. A place to find the latest and most helpful websites, books, and articles about issues related to patient safety.

The new website also fulfills a vital need of the Foundation- to share information about the successful patient safety programs that we have supported. Good things are happening in patient safety all over the country. We want to help spread the word so that these good things take root and replicate in new places where the need is dire.

We also wanted the site to be a place where people could connect with others. Why should the interesting, wonderful, and sometimes heartbreaking e-mails come just to my inbox? Wouldn't it be great to pass them along so that thousands of others can read, react and connect? Maybe by creating this online community, doctors, nurses, and families can come together and solve problems or help each other.

I think this website will achieve some of those goals. It will continue to evolve as we react to your ideas and the progress shaping patient safety as a field. We would really love your feedback- good or bad. It all helps.