1. Strobel, Sharon MS, RN

Article Content

In "Calling a Condition H(elp)" (November 2006), University of Pittsburgh Medical Center Shadyside's partnership between the patient and family and the clinician is a significant step in promoting patient safety. However, the journal report of Sorrel King's statement in the article that Josie King died at Johns Hopkins's Children's Center from "severe dehydration and misused narcotics" is misleading. Josie did not die because of one nurse's actions or a methadone dose. Her death resulted from a hierarchical health care culture leading to communication failure among all health care team members, physicians and nurses alike. Concerns raised by the parent and nurses were not understood or acted upon in a way that maintained her safety or prevented her death.


Since February 2001, the safety culture of the Children's Center has significantly changed. The staff have united to eliminate communication roadblocks. Multidisciplinary teams partnering chairpersons, directors, and staff routinely review issues that have or could affect care. In answering the question "How can the next patient be harmed?" any issue or concern will be addressed.


A pediatric rapid response team (composed of nurses, pharmacists, intensivists, pediatricians, and respiratory therapists) now responds "if you or the family are concerned, we are too." Families are strongly encouraged to voice concerns and staff are empowered to address them. Nurses have access to all members of the physician chain of command without reprisal. To foster effective communication with clinicians, staff are taught SBAR (Situation, Background, Assessment, Recommendation). The previous culture, where physicians were viewed as solely responsible for care, has shifted to multidisciplinary partnership and collaboration.


Josie's death stimulated remarkable improvements in our communication and safety culture. Josie King left a powerful legacy indeed.


1Nurse Manager, Infant/Preschool Unit (Strobel)


2Director of Pediatric Nursing (Phifer)


3Nurse Practitioner, Pediatric Pain Team (Billett)


4Chairman, Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, MD (Dover)