Josie King Essay

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Josie King Story Ray R Wiederholt ANC I Josie King was an 18 month old little girl that died on Feb 22, 2001 due to human error. She was admitted to the Johns Hopkins Hospital after receiving burns from a hot bath. She spent 10 days in the PICU. During her time in the PICU she had a PCA ordered. Her mother had said when she had pain the nurse would "push the button." But her mother said that rubbing her head would often help her pain subside. She was transferred to the ICF and her central line was removed. After her central line was removed she displayed signs of thirst. During a bath she was trying to drink the water because of her thirst. At one point, her mother noted that her eyes had rolled back in her head and she wanted the physician called, the nurse reassured her that this was normal. The mother was adamant that another nurse assess her. The second nurse concurred with the primary nurse. The next morning Josie had a dramatic change in condition and the physician was called. It was determined she had too much opiod analgesics in her system. Narcan was ordered and administered, Josie seemed be doing better. There was a verbal ordered received that Josie was not to receive anymore opiod analgesics. During the day the nurse assigned to care for Josie gave her a dose of dilaudid. Josie's mother questioned the dose but it was administered anyways. Josie expired two days later. Josie's cause of death was due to narcotic misuse and severe dehydration. These two causes could have been avoided but as Sorrel King so eloquently stated, "hospitals are a man made epidemic," and "human errors need a human solution" (King, 2002). There are numerous errors that attributed to Josie's death. Josie was placed on a PCA, at 18 months of age, she was not an appropriate patient to be on a PCA ("Barriers to Optimal, 1996"). Age specific considerations were not instituted. The

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