Nurse suicide follows infant tragedy - page 5

continued: How horrible for everyone in the situation...she had worked at Seattle Children's for 27 years, the article states.... Read More

  1. Visit  nursel56 profile page
    6
    This reminds me of an incident that happened when I was working with a fantastic new nurse in infant DOU who dosed a 6 wk old child with 10x the ordered amount of epinephrine - thank God the child made it through but the scene (and the look on her face) until we knew he would be OK is seared into my brain. It was awful for her! When you deconstruct how mistakes are made everyone learns. I would happily hand my child over for C to take care of at any time.
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  3. Visit  Esme12 profile page
    11
    Quote from CompleteUnknown
    This story breaks my heart too Esme12. As many have said, there but for the grace of God go any of us. I can't stop thinking about it.

    How do we as nurses deal with the possibility of making a devastating error? Is it something we should be thinking about more?

    How do we, as mothers and fathers, daughters and sons, deal with the possibility of a fellow health professional making a devastating mistake that results in the death of our own child, parent or spouse?

    How do we reassure our patients that we will keep them safe when the possibility of an error is ALWAYS there? How do we acknowledge to patients and families that errors are possible, without this frightening them, making them angry, or encouraging them to pick up the phone and contact a lawyer?

    Are there degrees of error? Is a calculation error more or less serious than a judgement error or an error caused by inattention or poor staffing or lack of time? Is an error more or less serious because of the outcome or because of the reasons it was made in the first place? Is it more or less or less serious depending on whether the patient is nine, nineteen or ninety? More or less serious depending on the condition of the patient prior to the error being made?

    Should there be some sort of 'no fault' compensation for the patient when serious errors are made?

    Is there a point where the systems, processes, policies and procedures, and checks and balances put into place after a serious error actually stop from us being effective and perhaps even lead to other unforeseen problems?

    We are humans, not perfect beings or machines, there will always be errors and some of them will have fatal outcomes. I've made my share of mistakes over the years, I'm just very very lucky that none of them resulted in permanent harm to the patient.
    This could happen to ANY of us.......those of us in critical care areas are more vunerable because the drugs are more dangerous and we use them often. I recall as a supervisor the pharmacy mixed doxycycline for an adult and 80 KILOgram adult........it was an 80 POUND child. That higher dose was given for several days every 8 hours......a seasoned nurse finally cared for the child and re-calculated the dose because it "seemed high". The pharmacy of course was sorry.....they "thought it was eighty kilos not eighty pounds". The MD who ordered the antibiotic REFUSED to change the dose (not a pedi MD) because it was "fine" ....I politely let him know we would not be hanging the dose....he told me he would have my job and report me to the board.....I told him I would be happy to meet with him in the morning in administration with the pharmacy.........I told him if he wanted it given he could come in to give it himself........

    you know who got written up? EVERY SINGLE NURSE WHO HUNG THE DRUG! because there was no mistake until the nurses gave it......... Thank God the child had no liver damage....and I was sopken to about being argumentative with the MD.........WHATEVER.......

    I just can't stop thinking about her.......... and it just makes me VERY sad......
    fiveofpeep, NurseShelly, GadgetRN71, and 8 others like this.
  4. Visit  RNforLongTime profile page
    3
    So so sad RIP Kim and Kaia
    Mrs. SnowStormRN, lindarn, and nursel56 like this.
  5. Visit  imintrouble profile page
    4
    We truly do hold lives in our hands. On some nights it's not the understaffing, the extra lifting, or the troublesome families that exhaust me. It's the responsibility of all those lives on my back that drains me.
    lindarn, nursel56, CompleteUnknown, and 1 other like this.
  6. Visit  hecallsmeDuchess profile page
    6
    This is a very, very sad situation. And a scary one too. I wonder what happened on that day that led to this medication error and I wonder how many times this nurse played it over and over in her mind wishing she could reverse the hands of time. I can't imagine what she must have gone through or what the family that lost the child must have gone through and is going through even now. I'm sure most parents however deep their grief would not have expected this outcome for the nurse. SO very tragic!
  7. Visit  CompleteUnknown profile page
    9
    Quote from Esme12
    This could happen to ANY of us.......those of us in critical care areas are more vunerable because the drugs are more dangerous and we use them often. I recall as a supervisor the pharmacy mixed doxycycline for an adult and 80 KILOgram adult........it was an 80 POUND child. That higher dose was given for several days every 8 hours......a seasoned nurse finally cared for the child and re-calculated the dose because it "seemed high". The pharmacy of course was sorry.....they "thought it was eighty kilos not eighty pounds". The MD who ordered the antibiotic REFUSED to change the dose (not a pedi MD) because it was "fine" ....I politely let him know we would not be hanging the dose....he told me he would have my job and report me to the board.....I told him I would be happy to meet with him in the morning in administration with the pharmacy.........I told him if he wanted it given he could come in to give it himself........

    you know who got written up? EVERY SINGLE NURSE WHO HUNG THE DRUG! because there was no mistake until the nurses gave it......... Thank God the child had no liver damage....and I was sopken to about being argumentative with the MD.........WHATEVER.......

    I just can't stop thinking about her.......... and it just makes me VERY sad......

    I totally agree with you. I can't help thinking that an error like the one in your post wouldn't have occurred back in the dark ages when nurses mixed their own antibiotics. Or, at least, it wouldn't have occurred multiple times. Now we not only have to check our own work, we have to check pharmacy's work as well.

    There is a blog I read sometimes, written by a surgeon. In one of the entries, he describes the 'graveyard' in his mind. This graveyard contains the tombstones of the patients who he feels died because of some sort of error in judgement on his part. He says he will never forget, or get over, these cases.

    That is what I find the most frightening of all - the fact that, like it or not, even the very best of us are going to have situations where we at least contributed to adverse outcomes, if not directly caused them. And that's what I think the general public needs to understand, not this idea that all mistakes are caused by 'bad nurses' who must 'pay for their crime' and that if only nurses would follow correct and ever more rigid 'proper procedure', medication errors would not occur.

    Some days I wonder why it is we keep showing up for work.
    fiveofpeep, NurseShelly, lindarn, and 6 others like this.
  8. Visit  nifrn profile page
    2
    and I wonder if the family of this precious baby sleeps any better at night knowing the nurse who cause the accidental death was so grief stricken she killed herself. they have every right to be angry, mad, to sue, scream, and cry. but her killing herself did nothing to help the healing process of that family, I would guess. it only benefited seattle children's who caused it by how they handle their policy on medication administration and how they treated a loyal 27 year veteran employee who helped heal thousands of children. so sad. I guess you have to be perfect to be a pediatric nurse or be prepared to suffer. I read the wa state board of nursing meetings and drug addicted nurses who have been caught numerous times stealing narcs etc are given more respect then she was.
    lindarn and bsnanat2 like this.
  9. Visit  cdsga profile page
    4
    I guess the saying goes "You're only as good as your last mistake". There's just no getting better over this situation. My gut aches for that nurse, knowing she just couldn't live anymore. I don't like harsh black and white, non compassionate colleagues who feel that they are judge jury and executioner. All I can say is for those who are that harsh, Karma comes around--just when you think you're mistake proof, WATCH OUT! It just may happen to you and some innocent patient. Hope you can live with that.
    lindarn, AtomicWoman, bsnanat2, and 1 other like this.
  10. Visit  RNbutterflykisses profile page
    1
    this is truly a sad story for both families involved. I wish they had done more to work with the nurse especially given she had worked for the hospital faithfully for 27years! a story like this should also be a wake up call to all of us as nurses about how important it is to double check the doses of medications and utilize second rn checks. as nurses we are on the frontline of care and the last check before the patient gets medicated. Eventhough we know doctors and pharmacists are smart, we can't always rely on them b/c they too are tired and make mistakes. we must remember that we know the patient best and should question orders, and if we cannot get clarification, them we need to follow the chain of command to ensure patient safety.

    i'll be keeping the families of both in my prayers. all the best to us nurses. let's be safe and practice with a questioning attitude.
    Last edit by TheCommuter on Apr 26, '11 : Reason: removed unapproved link
    AtomicWoman likes this.
  11. Visit  mdgradRN profile page
    1
    This is sad... may god bless her family and loved ones. may her soul rest in peace!
    AtomicWoman likes this.
  12. Visit  AtomicWoman profile page
    0
    How excruciatingly sad.
  13. Visit  Purf3ctMedicine profile page
    0
    this is so sad and horrible
  14. Visit  hic12345 profile page
    4
    The thing that is frustrating about this situation is that... this nurse was left out cold because she did not have the liability insurance which not every nurse is expected to have. in which she is not able to defend herself because she doesn't have the money to. how do you expect a nurse put on leave to be making money to defend her job and license. you'd think the hospital will back her up. ive worked in this hospital before and I would recommend every nurse at this institution to BUY LIABILITY INSURANCE!!!!!
    NurseShelly, Esme12, leslie :-D, and 1 other like this.


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