We are modernizing the Good Practices Guide. Learn more

Team communication

Let's talk

The patient as team member

  • Consider the patient as part of the team.
  • Listen and respond to the concerns of the patient or family.

Patients can contribute to their own safe care and risk management, but they need to feel welcome and encouraged to speak up, ask questions and voice concerns.

Case: The Josie King story

The following is a summary of an important patient safety case from the United States.

Josie King


Josie King was an 18-month-old child who climbed into a hot bath and suffered extensive body burns. She was admitted to a pediatric ICU at Johns Hopkins Children's Center in Baltimore. She stabilized and was transferred to an intermediate-care floor. She died there after a sequence of miscommunications.

Her mother had repeatedly voiced concerns about her daughter's steady deterioration and was repeatedly reassured by the residents and nurses that all was well. "In my case, no one was listening to me when I tried to tell the doctors and nurses that Josie didn't look right to me."


Josie acquired a catheter infection, her fluid status was not recognized and managed, and she became dehydrated. Narcotics that had been ordered stopped were still administered. She had a cardiac arrest and could not be resuscitated. Subsequently the Josie King Patient Safety Program was launched at the Johns Hopkins Children's Center.

Some patients are embarrassed or fearful to ask simple questions, or speak up when they perceive a problem is developing. Sometimes patients are deferential and assume that the healthcare providers, as experts, have the situation under control.