Read Josie King’s story:
https://www.healthleadersmedia.com/clinical-care/josies-story-teaches-hospitals-how-become-safer
Read the following safety techniques for patients:
https://josieking.org/resource-center/#for-caregivers
https://josieking.org/from-the-experts/#patient-safety
- Write your feelings about Josie and the culture of hiding mistakes and the approximately 98,000 persons that die each year in America because of medical errors.
- Answer the questions as thoroughly and concisely as possible.
- Be sure to reference any works that you utilize in answering the questions (Be sure that references are in APA format).
Reading Josie King’s story and the related materials on medical error, patient safety, and the culture of hiding mistakes elicits a mixture of sorrow, frustration, and a kind of resolve. Below are my reflections, organized around feelings, ethical issues, and implications, drawing in material from Josie King and the “From the Experts” and “Resource Center” pages.
What the story says, in brief
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Josie King was an eighteen‑month‑old child who was nearly well enough to go home after hospitalization, but through a cascade of miscommunication and error, she deteriorated. A methadone injection (administered by mistake) caused cardiac arrest, leading to multiple organ failure, then life support was withdrawn. Health Leaders Media
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Her mother, Sorrel King, founded the Josie King Foundation to prevent others from suffering similar harm. The Foundation works on initiatives like rapid‐response teams, “Condition H” (family/patient‐activated), care journals, improving communication, and transparency and disclosure when errors happen. Health Leaders Media+2Josie King Foundation+2
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The “From the Experts” section underscores that medical error isn’t just about individual caregivers’ mistakes, but about broken systems: communication failures, staffing, work environment, institutional culture. It describes tools like CUSP (Comprehensive Unit‐based Safety Program) to shift systems and culture. Josie King Foundation
My feelings
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Sorrow and grief. It is heartbreaking that a family lost a child when so many of the failures were preventable. The tragedy is compounded by the sense that Josie’s death might have been avoided with more attentive communication, checks, or systemic safeguards.
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Anger and frustration. Learning that each year in the U.S., an estimated ~98,000 people die due to medical errors (as reported by the Institute of Medicine in To Err Is Human) is deeply disturbing. That many lives lost due to avoidable errors is unacceptable. The idea that many hospitals had a culture of hiding mistakes (“under the rug”) rather than acknowledging and learning from them is frustrating. Health Leaders Media+1
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Empathy and admiration. I feel respect and admiration for Sorrel King, for taking profound grief and turning it into activism to improve patient safety. Also, respect for caregivers, safety scientists, and others who work to change culture, build better systems, and try to prevent future harm.
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Resolve / hope. Despite the tragedy, there is hope in the solutions: greater transparency, system redesign, empowerment of patients & families, communication, rapid‐response mechanisms. The fact that some hospitals are implementing changes means progress is possible.
Cultural problem: hiding mistakes
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In Josie’s narrative and in the “From the Experts” writing, one of the root issues is a culture in medical institutions where mistakes are concealed or minimized rather than openly discussed. This arises partly from fear (of litigation, of blame, of reputation damage) and partly from hierarchical structures and traditions that favor covering up rather than learning. Health Leaders Media+1
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Hiding mistakes blocks learning. If errors aren’t reported, nor root causes analyzed, then system failures persist. The safety science perspective from the Josie King Foundation stresses that outcomes (bad or good) come from how systems are designed; individuals may do their best but if the system is flawed, harm occurs. Josie King Foundation
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Also, hiding mistakes harms trust: between patients/families and providers, among staff, and between the public and medical institutions. Openness, honest communication, full disclosure—even apologies—are central ethical duties and also important in restoring trust and preventing future errors. Josie King Foundation+1
The scale: ~98,000 people dying each year
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The number is staggering. It means medical error is a major public health issue. When you multiply 98,000 by families, friends, lost productivity, suffering, the cost (human & financial) is very large. Josie’s story brings a face to those numbers—it’s not just statistics but real children, families, lives destroyed.
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The IOM report To Err Is Human (1999) put that figure forward, and although some have debated the precise number or method, what is clear is that preventable harm in medical care is common. Josie King Foundation+1
Ethical and systemic reflections
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Moral responsibility: Healthcare providers and institutions have an ethical obligation to “do no harm,” which not only includes avoiding mistakes but also designing systems so harm is less likely, and responding properly when harm does occur.
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Transparency and disclosure: When errors happen, disclosing to patients/families is not just ethically right; as the experts note, it also undermines fear, promotes trust, and may reduce litigation if handled openly. Josie King Foundation
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System vs individual blame: One of the key ideas is that errors are rarely purely individual failings; more often they occur because of system vulnerabilities. Blaming individuals without addressing system design leaves problems intact.
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Patient as partner: The materials encourage involving patients/families (e.g. care journal, Speak Up programs, patient‐activated rapid response). Patients are not passive recipients but can help detect potential harm. This has ethical importance: respect for autonomy, dignity, empowerment.
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Culture change required: Shifting from hiding mistakes to owning them requires leadership, organizational policies that support full disclosure/apology, non‐punitive reporting, learning orientation.
What can / should be done (some of what Josie King’s work suggests, plus additional thoughts)
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Hospitals should implement transparent error reporting systems: non‑punitive, confidential, that encourage staff to report near misses & errors.
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Leadership must foster “just culture” rather than blame culture: accountability does not equal punishment for honest error, but responsibility to learn and improve.
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Communication training among staff, and between staff and patients/families. Use of journals, checklists, family involved in care plans.
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Rapid response systems that patients/families can access (like “Condition H”) so that when a caregiver or family senses something is wrong, they can call for help. Health Leaders Media+1
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Full disclosure policies: when error occurs, providers should explain what happened, why, what is being done to prevent re‐occurrence.
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System redesign: addressing staffing issues, workloads, handoffs, redundancy, equipment problems, communication flows.
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Education and awareness: for all caregivers (doctors, nurses, staff) about safety science, about human factors, system failure, etc.
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Patient/family empowerment: encouraging patients and families to ask questions, verify identity, keep track of medications, use checklists, etc. The Josie King Foundation’s “Tips for Patients and Families” emphasizes that. Josie King Foundation
My concluding thoughts
Josie’s story is a poignant reminder that medical care, for all its advances, is still fallible. The gap between the ideal of safety and the reality of error is wide—but it’s not insurmountable. The fact that so many people die each year from avoidable errors is morally unacceptable, yet also a call to action.
Change demands courage—from individuals (to speak up), from families (to demand transparency), and from institutions (to admit error, redesign systems, foster cultures that value safety over prestige or blame). Josie’s life (and death) imposes a responsibility: to bring about a culture where her story (and those like it) become rarer, where mistakes are visible, acknowledged, learned from, and where patient safety is truly central.
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