On March 4, 2001, George Dover rang the doorbell of a Baltimore County home.

The director of the Johns Hopkins Children’s Center had come to the home of Josie King to apologize to the grieving parents.

Karen Nitkin and Lisa Broadhead report in the blog article An End to Error, "The day Josie died, her Johns Hopkins-affiliated pediatrician, Lauren Bogue, encouraged Dover to visit the King family and accept responsibility on behalf of Johns Hopkins. The unusual proposal won full support from Johns Hopkins leadership—even its lawyers."

Read the full article An End to Error

What happened to Josie? Michele Cohen Marill shares in the Medscape article Can doctors and nurses be taught to get along?, "Almost 20 years ago, toddler Josie King turned on the bathtub faucet and climbed in. By the time her mother heard her screams, scalding water had caused second-degree burns on more than half of the 18-month-old's body."

Josie received extensive treatment at the hospital and was almost ready to be discharged. But she died of septic shock exacerbated by an undetected central line infection, severe dehydration and inappropriate opioid administration.

Her mother, Sorrel King, tells the story and explains how Josie’s death led her to work on improving patient safety. Watch the video What happened to Josie?

Josie’s Story, written by Sorrel King, is used as an educational tool in the healthcare industry. More about Josie's Story: The Book

Get it on Amazon - Josie's Story

The Institute for Healthcare Improvement has created a learning module based on Josie King's tragic story. Access it here.

Karen Nitkin and Lisa Broadhead say, "On June 2, 2001, a second tragedy occurred. Ellen Roche, a healthy 24-year-old technician at Johns Hopkins’ Asthma and Allergy Center, died of lung failure less than a month after inhaling an irritant medication while participating in an asthma research study. The two deaths shattered Johns Hopkins, propelling what some consider the most significant culture change in its history." The blog article An End to Error describes the interventions and measures adopted by John Hopkins to reduce preventable deaths. More than that, the article reverberates with the courage, transparency, leadership, accountability and ouch-like honesty exhibited by the clinical, administrative and executive teams at John Hopkins.

Josie's Story provides base material for simulation-based healthcare education in collaboration, behavioral change and conflict management. Learning specialists and healthcare simulation professionals are encouraged to integrate Josie's Story with in-house learning programs.

Michael Wilkes, MD, MPH, PhD, internist and professor at the University of California, Davis says, "Working as partners with other healthcare professionals needs to be done early; it needs to be done regularly. And it can't be confined to just the classroom. The learners need to be in environments where people are working together."

Author's shameless nagging starts here: Links in this article are hand-picked and worthy of your attention. Don't just skim through this article. Click on the links, read the linked articles, watch the video. The information is free; it is a gift of emotional courage. Would you rather make a mistake to acquire the learning?