The case of Josie King was an unnecessary and unfortunate that could have been prevented if there were better communication and interventions done by the healthcare staff. One safety measure that should have occurred in this situation was the communication between staff. When the doctor gave the orders for medication to be changed they were verbally communicated. With verbal communication, meaning and detail can be easily lost while giving and receiving the order. With the acute of a patient case, it would have been in the best interest of the patient to have written orders to occur and discussed at the patient bedside in order to ensure proper communication. Another safety measure that should have occurred is titration of the opioids. With such a young child and the…show more content… Along with the improper administration with this medication, there was discrepancy in what the mother knew to be the plan of care for her child and what the nurse believed to be true. The mother questioned the nurse why the methadone was being given when the doctor had said it was to be discontinued, instead of the nurse double checking her orders and ensuring the patient safety and medication rights, the nurse administered the medication which ultimately built up and lead to Josie’s death. Clearly in the case of Josie King, the care by the staff should have been handled differently. When it comes to sentinel events, such as this, it is important of the healthcare team to look back at the case to see what events lead up to the death and what should have been done differently to ensure that an event like this doesn’t occur again. One difference that that should have occurred was to listen to the family of the patient. The mothers concerns of her daughters condition were
