When Nurses Make Fatal Mistakes

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    All practitioners make mistakes. To err is human. But how do we treat nurses who make deadly mistakes?

    When Nurses Make Fatal Mistakes

    Jessica's Story

    Jessica was a young, conscientious nurse in her first year of nursing.

    Jessica was having a typical busy day on Tele. One of her patients, a middle aged male in Room 4152, was on a Pronestyl drip for arrhythmias. Pronestyl is an antiarrhythmic drug. When the cardiologist rounded early that morning, he wrote an order that the Pronestyl drip be discontinued.

    Around 1500 that same day, a code was called in Room 4152. The patient was in ventricular tachycardia and despite all resuscitative efforts went into ventricular fibrillation. The patient died.

    Only after the patient was pronounced did someone look up to see the Pronestyl drip running.

    I observed all of this from the distance of a staff nurse who was not privy to whatever discipline took place. I can still recall the sick feeling I had when I heard about the error. Almost as if I had endured a close call myself.

    In the following weeks, I remember realizing that Jessica was gone. Did she quit or was she fired? No one spoke about it. Where did she go? Did she recover from her mistake? I still think of her and wonder where she is and what’s she’s doing. My belief is she quit nursing at that time.

    I do not believe the organization terminated her, because it was against the culture at the time.

    ​Wrong Blood

    At that same organization, an RN in ICU who was managing 3 blood transfusions at one time hung the wrong blood and the patient (a terminal patient) died as a result. She was not fired and went on to practice for many more years.

    She appeared to have resilience and bounced back. But not all second victims of fatal errors are able to recover.

    Medication Error

    There’s the story of Kim Hiatt, an RN who worked in Seattle Children’s Hospital ICU. Kim had worked there 24 years and by all accounts was a dedicated, compassionate nurse with a heart for families.

    On September 14, 2010, Kim received a verbal order to administer 140 milligrams of calcium chloride IV to her patient, a nine month old. She drew up 14 mLs because 14 mLs X 10 milligrams per mL = 140 milligrams. She labeled the syringe with the dosage.

    Tragically, she was wrong. There were 100 milligrams of calcium chloride per mL. Not 10. Kim should have given 1.4 mLs. Not 14 mLs.

    The mistake was not uncovered until hours later when the nine month old’s heart rate was faster than expected and a blood level of calcium chloride revealed abnormally high levels.

    Kim was immediately ordered to leave, escorted out of the facility, and subsequently fired.

    The nine month old baby died 5 days later. It is not clear how much the error contributed to the death as the baby had severe heart problems and was described as frail.

    Meanwhile the Washington State Department of Health opened an investigation to decide if Kim could keep her nursing license. She was given 4 years probation where she was to be supervised when giving meds.

    On April 3, 2011, 50 year old Kim, a previously highly regarded NICU nurse and now a pariah, and no longer able to cope, hanged herself in her basement.

    In Kim’s case, the facility did not have sufficient safeguards in place to help prevent the error. In She did not violate policy. The doctor gave a verbal order, which was permitted, and Kim performed an independent calculation, which was permitted at the time.

    Some claim an atmosphere of fear followed Kim’s mistake and subsequent firing- nurses at Seattle Children’s Hospital were fearful to report errors believing they could lose their jobs.

    ​Second Victims - The Nurse

    To err is human, as the Institute of Medicine tells us. It also tells us that a series of adverse events can rarely be attributed to one person.

    In a just culture, mistakes are differentiated from recklessness, and systems are examined for causative factors.

    Second victims of trauma are often overlooked as needing support and compassion. Patient safety is dependent upon not only preventing mistakes, but our actions following mistakes.
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    24 Comments

  3. by   Susie2310
    It is true that everyone makes mistakes, but that does not absolve us from personal responsibility for doing our very best to safely administer medications and from ensuring we have safe medication administration habits. Although we don't administer medications in a void that excludes other factors that can and do contribute to our ability to safely administer them, the fact is that we as nurses are responsible for the final checks before the medication reaches the patient.

    As far as what the consequences for the nurse who makes a medication error that kills or seriously harms a patient should be; I don't believe there should be no employment consequences although I know that many would like this. The risk of making this type of error is part of our professional responsibility, and safe medication administration is part of our duty of care to our patients. The cost of the personal consequences that the individual nurse bears in these types of situations is also something to consider, I believe, when one makes the decision to commence nursing training.
  4. by   RobbiRN
    "In Kim’s case, the facility did not have sufficient safeguards in place to help prevent the error."

    Can a facility ever have enough safeguards in place to prevent all errors?

    If errors could be completely eliminated by removing the human factor -- critical thought, informed decisions, and subsequent responsibility -- we would no longer need nurses to administer medications. Yes, we can still improve the system. But we can't remove art from medicine. It's never just black and white because there are too many variables. Our patient's conditions change constantly. A valid doctor's order doesn't make an intervention right, sensible or defensible. Ongoing critical thinking, and the responsibility that goes with it, is what makes nurses necessary and highly vulnerable. No wonder you felt the pain when a colleague made a mistake; it could have been you, me, or any of us.

    I can only imagine how differently the first scenario would have played out if the RN had stopped the drip as ordered only to have the patient go into V-tach 10 minutes later. Probably wouldn't have even been reviewed. . .
  5. by   Nurse Beth
    Quote from RobbiRN
    "In Kim’s case, the facility did not have sufficient safeguards in place to help prevent the error."

    Can a facility ever have enough safeguards in place to prevent all errors?

    A valid doctor's order doesn't make an intervention right, sensible or defensible. Ongoing critical thinking, and the responsibility that goes with it, is what makes nurses necessary and highly vulnerable. No wonder you felt the pain when a colleague made a mistake; it could have been you, me, or any of us.

    I can only imagine how differently the first scenario would have played out if the RN had stopped the drip as ordered only to have the patient go into V-tach 10 minutes later. Probably wouldn't have even been reviewed. . .
    There will always be mistakes, you are right. In Kim's case, though, the Seattle hospital as much as acknowledged they were lacking in safety and instituted many changes afterwards.

    For me, drawing up 14 mLs of anything IV push would give me pause, but I also know BrainFail happens.

    The pronestyl most likely caused the Vtach/Vfib because it has pro-arrhythmic properties and it was above therapeutic levels, unfortunately.
  6. by   Daisy4RN
    Unfortunately mistakes will happen no matter how "good" a nurse is because we are all human and humans make mistakes, there is no getting around that. I think that most mistakes occur due to systemic failures, and mostly related to time factors. When a nurse is overloaded (which is most of the time) and cannot even think straight of course this will happen. Most of the time it is easier for the hospital to simply blame the nurse instead of fixing the systemic problems. I have also seen these types of mistakes (from both seasoned and new nurses) and believe that time was probably the primary factor. I agree that there should be safety checks etc. in place for certain meds but the whole picture should be looked at and considered. Too many checks/policies/procedures for stupid things just take more time and put the nurse in a vicious circle. I think that the current environment only gets worse as patient acuity increases and patient assignments do not reflect this. I feel bad for any nurse that has had to go through this and without knowing the situation I think that the hospitals/admin carry the majority of the responsibility. Most Nurse Managers/administrations know it is just too much but don't seem to care.
  7. by   julianp
    I've found that facilities with overly complicated safety systems make failure more possible. We all make errors of some type. However, I think fatigue and the lack of breaks at most hospitals contribute more than anything to errors.
  8. by   Ruby Vee
    I cannot help but wonder at the purpose of this "article." Is it to point out that nurses make mistakes? Surely that cannot surprise anyone. Is the purpose to point out that nurses sometimes make fatal mistakes? I doubt that surprises anyone, either.

    People make mistakes; mistakes are inevitable. There is no system ever designed that is so "foolproof" it can keep even even well-meaning, conscientious folks from ever making mistakes, much less keep fools from making them. What I had expected was some sort of advice on what to do after you've made a mistake, how to forgive yourself, how to deal with your colleagues or your patient in the aftermath. Perhaps this is the first in a series of articles to explore this subject?
  9. by   Nurse Beth
    Quote from Ruby Vee
    I cannot help but wonder at the purpose of this "article." Is it to point out that nurses make mistakes? Surely that cannot surprise anyone. Is the purpose to point out that nurses sometimes make fatal mistakes? I doubt that surprises anyone, either.

    People make mistakes; mistakes are inevitable. There is no system ever designed that is so "foolproof" it can keep even even well-meaning, conscientious folks from ever making mistakes, much less keep fools from making them. What I had expected was some sort of advice on what to do after you've made a mistake, how to forgive yourself, how to deal with your colleagues or your patient in the aftermath. Perhaps this is the first in a series of articles to explore this subject?
    Good question. I want to expand more on a "just culture" where maybe nurses would feel freer to report errors and near misses. I also feel that doctors and nurses both make very serious errors that cause harm...but doctors and nurses are treated entirely differently afterwards.

    The simple answer is to blame and shame the nurse, but there are so many reasons that contribute to errors. Idk if readers want to read anything along any of those lines, but those are the things I feel strongly about
  10. by   Apples&Oranges
    Beth,

    I really appreciated this article, especially as I am working on case studies for school that focus on patient safety and med errors. Like Ruby Vee (who has given me great advice in the past,) I also felt that it ended a bit abruptly. I think a series on patient safety, med errors, consequences (new and experienced nurses need these reminders, we get complacent!) and how to avoid them, defend against them (both proactively and after the fact) sounds like a great idea. This may have been a "one and done" for you, but it would be great if one of our guides would jump in and write a series of articles/case studies focused on exactly this.

    I frequent the patient safety forum, and would love to read some interactive, case study type articles from someone with a legal/LNC/risk management/Patient Safety Officer type of background. Remember when a small group posted some great clinical case studies a couple years back? Wasn't Esme involved? I really hoped that would keep going.

    What a great learning tool something like that would be in this realm.

    Thanks, Beth. Keep it going!
  11. by   Apples&Oranges
    "Idk if readers want to read anything along any of those lines, but those are the things I feel strongly about "


    I DO, I DO!!!
    Last edit by Apples&Oranges on Feb 15 : Reason: Absolutely cannot make the quote feature work for me.
  12. by   Susie2310
    Quote from Nurse Beth
    Good question. I want to expand more on a "just culture" where maybe nurses would feel freer to report errors and near misses. I also feel that doctors and nurses both make very serious errors that cause harm...but doctors and nurses are treated entirely differently afterwards.

    The simple answer is to blame and shame the nurse, but there are so many reasons that contribute to errors. Idk if readers want to read anything along any of those lines, but those are the things I feel strongly about
    There are people who will lie about their mistakes and/or try to hide them if they perceive there will be negative consequences for them such as being reported to their state Board of nursing, disciplinary procedures, loss of employment etc. While I understand the intentions of a "Just Culture" I think in some respects it encourages complacency among practitioners even though it's intention is to encourage practitioners to feel safe enough to disclose their error/s in a non-punitive environment for the good of the patient so steps can be taken to discover the factors (both system and individual) that contributed to the error/s in order to prevent them happening again.

    I think it is human nature to want there to be painless consequences when we make big mistakes and sentinel events occur, but this isn't respectful of the patients who are killed/injured or who receive wrong procedures etc. or of the suffering they and their families go through.

    As far as nurses and doctors making very serious errors that cause harm being treated differently, I haven't found this to be true in my experience when the errors were serious. The doctors lost their jobs, were reported to their medical Board, had conditions applied to their licenses and had to undergo monitored/supervised practice just the same as happens to nurses.
    Last edit by Susie2310 on Feb 15
  13. by   Nurse Beth
    Quote from Susie2310
    While I understand the intentions of a "Just Culture" I think in some respects it encourages complacency among practitioners even though it's intention is to encourage practitioners to feel safe enough to disclose their error/s in a non-punitive environment for the good of the patient so steps can be taken to discover the factors (both system and individual) that contributed to the error/s in order to prevent them happening again.

    I think it is human nature to want there to be painless consequences when we make big mistakes and sentinel events occur, but this isn't respectful of the patients who are killed/injured or who receive wrong procedures etc. or of the suffering they and their families go through.
    I have to say I've never worked in a "just culture" but I believe the intent of a just culture is patient safety. I know whenever I've made a mistake, I punished myself far worse than my nurse manager ever could, or did.

    I think complacency comes from within.
  14. by   Nurse Beth
    Thanks for the feedback, Apples&Oranges, appreciate all of it

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