Important Baltimore Sun piece on hospital errors marred by undervaluation of nursing

December 14-15, 2003 -- On these two days, the Baltimore Sun published Erica Niedowski's massive feature about Baltimore's Sorrel King who, following the death of her daughter Josie at Johns Hopkins Hospital due to preventable dehydration, joined the hospital in a comprehensive, influential effort to reduce the risk of such errors. This moving piece makes valuable points about how Ms. King, Hopkins and other hospitals are trying to prevent future errors, but its physician-centric focus results in a failure to recognize the importance of nurses in resolving these problems.

The article tells how 18-month-old Josie King suffered second degree burns over 60% of her body in a bathtub accident. She was treated at the Hopkins Children's Center, receiving skin grafts and spending most of her time in the pediatric ICU. Though after about two weeks Josie's burns were healing and she was well enough to be transferred to an intermediate care unit, she developed dehydration, a condition her mother noticed first but that the health care staff was apparently slow to recognize. She also developed other complications, including an infection that prompted physicians to remove her central line, which was not replaced. The article describes the voluminous records about Josie's condition that were generated, including the bodily "ins" and "outs" that nurses typically record, which are critical to detecting dehydration. Despite some belated efforts to hydrate Josie, the toddler went into cardiac arrest, and she could not be revived before suffering severe brain damage. Josie died at Hopkins three weeks after the accident.

Sorrel King was at first eager to punish Hopkins for her daughter's death. But eventually, responding to an unusual willingness on the hospital's part to accept responsibility and improve, and mindful of her own promise that she would make something good come of her daughter's death, King joined forces with the hospital to implement changes that would make future errors less likely. The piece includes a detailed discussion of the complexity of modern hospital care, how mistakes can happen, and the implications for patient outcomes. A Hopkins panel that investigated Josie's death pointed to communication problems among the physicians and nurses, and a failure to listen to Sorrel King. It also concluded that the "temporary agency nurse" caring for Josie on the day her heart stopped should have been more aggressive in "alerting physicians" to the child's problems, and that Josie's central line should have been replaced, a problem that hindered efforts to resuscitate her. Physicians wondered if all the "ins" and "outs" had been accurately measured, though as the article notes, other warning signs were also not heeded.

Recent changes at Hopkins, some made in response to Josie's death, include a computerized system for prescriptions to reduce the risk of medication errors; increased efforts to reduce hospital infections, such as through a nurse-enforced safety checklist for physicians inserting catheters; the inclusion of nurses, pharmacists and other professionals on rounds in some units; efforts to make patient safety a part of the medical and nursing schools' curricula; and various measures to improve collaboration and the accuracy and ready availability of patient data. The efforts of King and Hopkins have apparently already had a positive impact on hospitals throughout the nation and abroad. King herself, despite her intense grief, has traveled the nation sharing her experiences and her perspective.

As the above description shows, the article does indicate that nurses play some role in patient outcomes, including the tragedy that befell Josie King. However, on the whole the piece presents nurses as little more than anonymous, subordinate physician helpers. There is no suggestion that nurses are autonomous professionals with independent legal and ethical responsibilities to patients. There is no suggestion that the main function of modern hospitals is to provide nursing care to patients like Josie King. Nor does the article show any awareness that nurses, as patient advocates, have long been at the forefront of promoting the kind of systemic reforms it discusses. Thus, the piece fails to give an adequate picture of the importance of nursing or nurses in the avoidance of mistakes like the ones that claimed Josie.

Based on the story's account, Josie's death from dehydration appears to have been, at least at the most obvious level, a nursing "failure to rescue." Dehydration is a condition that a nurse is most likely to detect, and for which a nurse is most likely to initiate a resolution. Indeed, hospital nurses spend far more time with patients than physicians or any other health professionals do. Nurses have the primary responsibility to monitor the status of post-operative patients like Josie. This does not mean they mechanically record data just so physicians can see it, as the article implies, but that they monitor numerous aspects of each patient's condition, using their own scientific training, and formulate appropriate interventions, including actions that involve physicians and many that do not. More broadly, studies have shown that nurses prevent a huge number of medical errors from harming patients, and conversely, that nursing errors such as failure to rescue and failure to detect medication errors--often brought on by the critical short-staffing that plagues hospitals today--are a significant factor in adverse outcomes.

The article states that "[p]atients know better than anyone else how they're feeling, and physicians rely on them to explain their symptoms and explain, for instance, how much pain they're in or how soundly they slept. With young patients like Josie who can't communicate well, input from parents is essential." Yes, but what is missing from this picture? Of course, it is nurses--who are central to all of this communication, and who are the health professionals primarily focused on issues like pain, as part of their unique duty to protect the overall well-being of their patients.

At another point, the article describes Sorrel King confronting a nurse who was about to give Josie methadone. King had understood that Josie would not be given narcotics at that point, but physicians had apparently changed their minds without telling her. The article says that in response to King, "[t]he nurse replied that the order had been changed, and gave the child the medicine." Soon after, the child's heart stopped. There appears to be some dispute as to what role the medication may have played, but regardless, it is a nurse's job to independently assess whether patients should receive prescribed medications, and to explain such planned care to patients' families--not to simply do whatever a physician says and respond to patient concerns by citing physician "orders." Whatever the nurse in this particular case may have done, the article's failure to understand these roles means readers will not understand what happened here, or some of the ways in which future problems could be averted.

On the whole, readers are unlikely to understand the key role nursing undoubtedly played in Josie's three weeks at Hopkins. Nurses' central role in protecting patients means giving them their share of the credit when things go right, and their share of the responsibility when things do not. The piece's only direct suggestions that nursing may have played a role in the child's death--the statements that not all the vital patient data may have been accurately recorded, and that the "temporary agency nurse" should have communicated with the physicians better--only underline the inadequacy of its treatment of nursing issues. Despite the apparently central role of the agency nurse, the story does not even mention the possibility that short-staffing or nurse fatigue may have played a role in these apparent errors. Could it be that it never occurred to the Baltimore Sun to ask the nurses who cared for Josie what they thought? Were they short-staffed? Was forced overtime a factor? Were the nurses able to accurately record all her data, or indeed, was some of the data recorded by non-RN assistive personnel, a common practice at today's bottom-line obsessed hospitals? What did the nurses think of efforts to hydrate Josie? Did any speak with physicians or other nurses about the problem? Who was the agency nurse? Was she concerned about giving the methadone? Given their front-line role, do nurses have any ideas about reducing hospital errors? The unanswered questions go on and on.

The article's undervaluing of nursing is inseparable from its apparent belief that physicians direct all important care and are the only ones ultimately responsible for the well-being of hospital patients. The Children's Center's chief pediatrician, George J. Dover, is described more than once as being the "head" of the Center, though simply directing the physician staff does not confer that position; hospital nurses are managed by other nurses, and they do not report to the physician staff. In addition, by our count, the piece quotes or describes the actions of no less than nine specific, named Hopkins physicians, some of them many times. For instance, the actions and attributes of Dover, patient safety expert Peter J. Pronovost, and director of pediatric trauma Charles N. Paidas are described so fully that it could be said that the piece contains short profiles of them. Statements attributed to Dover and Paidas give the impression that they direct all aspects of care, rather than just medical care. Photos accompanying the article show and name seven different physicians, and only one nurse, who is not mentioned in the article text, and who seems to have been included mostly because she is standing next to Pronovost on morning rounds. The overall impression is that physicians are the sole health care professionals taking any kind of leadership role in improving patient safety at Hopkins.

In contrast to the portrayal of physicians, not one nurse is quoted--or even named--in the entire text of the article. An explanatory box at the end of the article notes that it is "based on interviews with more than 30 people, including Sorrel and [her husband] Tony King, their family, physicians who cared for Josie King at the Johns Hopkins Children's Center, officials at the Johns Hopkins University and Hospital, and patient safety experts." Is it possible that, despite nurses' central role in protecting patients from health care errors and their critical role in the care of Josie King, the author of this enormous article did not speak to a single nurse?

These problems amount to more than just a disservice to the nursing profession. They also detract from the overall value of this otherwise commendable article, which does succeed in highlighting the importance of reducing hospital errors, as well as Ms. King's and Hopkins' leadership in that urgent effort.

See Erika Niedowski's December 14 article "How medical errors took a little girl's life" and her Dec. 15 article "From tragedy, a quest for safer care."

Comments may be sent to journalist Erica Niedowski at erika.niedowski@baltsun.com

Also see a letter to the editor about this article that claimed the answer to solving many medical errors was to increase support to the nursing profession--written by a physician.