In 2001, 18-month-old Josie King was hospitalized at Johns Hopkins Children’s Center with burns she had sustained in a bathtub accident. Josie responded well to treatment at first, but her condition quickly deteriorated. When her mother, Sorrel King, expressed concern, the staff nurses and physicians repeatedly dismissed them, and two days before her scheduled discharge Josie died. The cause was dehydration and a wrongly administered opioid—the result of a series of errors the hospital acknowledged.

Ms. King has since devoted herself to the elimination of medical errors, founding the Josie King Foundation (www.josieking.org) and addressing clinicians, policy-makers, and consumers on the importance of creating a “culture of safety.” And the need is pressing. According to a 2000 Institute of Medicine report, up to 98,000 people die from medical errors each year (IOM, 2000); nearly 10 years after that report’s publication, despite improved patient-safety systems, a 2009 report gave a grade of C+ to efforts to empower patients to prevent errors (Wachter, 2009).

Tami Minnier, MSN, RN, FACHE, heard Ms. King speak in 2005, and the message was clear: if the staff had listened to her mother’s concerns, Josie would have lived. “When I came back to work the following Monday,” said Ms. Minnier, at the time chief nursing officer at the University of Pittsburgh Medical Center (UPMC) at Shadyside, “I told my chief medical officer, ‘We’re going to let patients and families call a rapid-response team’—a group of staff who are designated by the hospital to respond immediately to other staff’s requests for help with critical or emergency patient situations. He thought I was insane.”

Shadyside had been one of the first three hospitals to participate in Transforming Care at the Bedside (TCAB), an initiative of the Institute for Healthcare Improvement (IHI) and The Robert Wood Johnson Foundation, enabling front-line nurses to test their ideas for improving the safety and quality of care. Ms. Minnier called on Sorrel King to work with the nurses in Shadyside’s TCAB unit in creating what they called Condition H (or Condition Help). They interviewed patients and families about when and why they might call for a rapid-response team, consisting of a nurse administrator, a physician, a staff nurse, and a patient advocate who would convene immediately in response to a patient’s or visitor’s call. They held drills with staff, and within six months, Condition H went live in the hospital’s TCAB unit.

While some staff feared that patients would abuse the hotline, that concern was not borne out. Today, patients and families throughout UPMC’s 13 acute care hospitals can use Condition H. They receive information on how to make the call (dial 3131 and say, “Condition H”) during admission and through posters, a video and stickers placed on patients’ phones.

Ms. Minnier is now chief quality officer at UPMC and monitors the use of Condition H. At Shadyside, a 500-bed hospital, two or three calls are made each month, and only a few patients have called twice during the same admission. An analysis of the 45 calls made in the first 17 months showed that inadequately managed pain was the most frequent impetus for calls, and more than 60 percent of the calls led to interventions that were deemed instrumental in preventing a patient-safety event.

Condition H is spreading and serves as one example of the changes hospitals have adopted using TCAB methods. Reports on TCAB have shown that it generates improved outcomes, greater patient and family satisfaction, and reduced turnover of nurses (Hassmiller, 2009).

Sorrel King addressed medical and nursing students at an IHI-sponsored event in 2009 and spoke strongly in favor of Condition H. “Had I been able to push a button for a rapid-response team, that team would have come, they would have assessed Josie and…said one thing: the child is thirsty,” Ms. King said. “They would have given her a drink, and she never would have died.” (King, 2009).