Sorrel King's 18-month-old daughter Josie was recovering from second degree burns at Johns Hopkins Hospital in Baltimore when a communication breakdown caused a deadly misstep.
As King watched, a nurse gave Josie a methadone injection despite verbal orders to the contrary, assuring King that the order had been changed.
Josie, who was about to be released from the hospital, went into cardiac arrest.
"I took one look at her ran into the hallway and screamed for help," King said.
Josie died two days later.
Hospital errors, like the one that led to Josie's death, are common. As many as one-third of hospital visits leads to hospital-related injuries, according to a report published today in Health Affairs.
"We know these types of injuries can increase the risk of other complications -- even death," said Dr. David Classen, the study's lead author and an associate professor of medicine at the University of Utah in Salt Lake City. "They also increase the risk of readmissions and long-term disability."
Using the "global trigger tool" -- a checklist executed by a third party reviewing medical records -- Classen and colleagues showed that as many as 90 percent of hospital errors are missed by current surveillance systems.
"Clearly, we've made improvements, because hospitals have shown a reduction in mortality and the rate of some infections," Classen said. "But this study suggests there's a whole lot more work to do."
The study revealed that current methods for tracking hospital errors may be inadequate and may be skewing data on the effectiveness efforts to improve patient safety.
"I think the next step is to push policy makers to develop much better tools for measuring hospital safety and get them into hospitals," Classen said.
Since Josie's death in 2001, improving patient safety has been a priority among U.S. hospitals.
"A year after Josie died at my hospital, Sorrel asked me if I could tell her that Josie would be less likely to die. Her words have haunted me," said Dr. Peter Pronovost, a professor of anesthesiology and critical care medicine and surgery, and the director of the quality and safety research group, at Johns Hopkins Medical Institution.
Pronovost has since been a leader in the national effort to improve patient safety.
"Now, a decade after Josie died, we still can't give her an answer," Pronovost said.
While modern-day medicine continues to advance, the science of health care delivery has remained relatively stagnant, Pronovost said.
"We need to invest in the science of health care delivery," he said. "The U.S. spends two pennies on the science of health care delivery for every dollar it spends on finding new genes."
Pronovost said King has helped to galvanize research support for health care delivery by acting as a face for patients, who "deserve better." He hopes error reporting tools, like the global trigger tool reported by Classen and colleagues, shed light on the lingering problem of hospital errors.
"Mistakes happen at every hospital. Our current response is to tell the doctors and nurses to be careful instead of making it impossible for mistakes to happen," Pronovost said, adding that device makers and systems engineers should also be appointed with the task of improving patient safety.
With the settlement from Josie's case, King created the Josie King Foundation with a simple mission: "To prevent patients from being harmed or killed by medical errors."