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New guideline empowers patients and families to call for rapid assistance
Quality Improvement Monitor, December 7, 2007
Had Sorrel King been able to launch a rapid response team at the hospital where she watched her 18-month-old daughter, Josie, deteriorate and ultimately die, she is convinced her little girl could have been saved.
"There's no doubt in my mind; she would be alive," King says. "Numerous fresh sets of eyes would have seen her, and they would not have said, 'Oh, she's going home in two days; she'll be fine.' They would have picked up on a lot of things that other people didn't."
Instead, King pleaded with clinicians to do something, to no avail. Josie's eyes rolled toward the back of her head, her skin turned a pallid hue, and she seemed desperate for a drink of water.
Staff members at Johns Hopkins Hospital assured her Josie would be fine. On February 22, 2001, Josie died at one of the most renowned hospitals in the country from dehydration and misused narcotics.
Six years after Josie's death, King is hopeful that a new Joint Commission (formerly JCAHO) requirement will prevent other patients and families from suffering a similar fate. National Patient Safety Goal (NPSG) 16A calls on hospitals to rapidly respond when a patient's condition is quickly deteriorating. One of the implementation expectations for the new goal, A3, asks organizations to empower patients and their families to call for immediate assistance if they believe something is seriously awry.
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