Nurse suicide follows infant tragedy - page 6

by babyRN.

32,948 Views | 97 Comments

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


  1. 8
    Support??? There is no support for nurses who make mistakes and cost a life. This profession is NO JOKE. When you make a mistake, your own peers will desert you. It's horrible. Some feel bad for you, pity you, sympathize with you, but they have no idea what it takes to get your profession back. When you have worked this long (over 20 years) in a profession that you are called to, it is part of your identity/persona. If you are a nurse, your job doesn't stop when you leave the workplace. Family, friends, etc call on you for advice, help on your off hours. It's a 24-7 deal. This is a clarion call to all nurses to support and comfort those who are faced with this type of problem. Career change counseling, networking are all needed to get the injured and traumatized nurse back on their feet. Financial assistance, and psychological counseling are necessary. No one intends for bad things to happen-of course there are a few wacko's- but to treat someone like this was intentional actions is so cold and heartless. No wonder she lost hope. It's a hard blow for us all. We all are one mistake away from this very situation. BELIEVE IT!!!
    fiveofpeep, DeLana_RN, AtomicWoman, and 5 others like this.
  2. 11
    Quote from kids
    I am sorry for the losses suffered by families on both sides of this tragedy but I just can't get on board with the idea that the hospital threw the nurse under the bus.

    For whatever reason she made a mistake that resulted in a death.
    Accidents and mistakes happen but they still have consequences and you're still responsible for the outcome.
    If you kill a patient you don't get to keep your job. Harsh? Yes but it's a natural consequence whether you've been on the job for 27 years or 27 days.

    Causing the death of a patient is a career breaker even if the BoN eventually clears you to practice. To the hospital's insurance company and to the insurance company of any future employers it doesn't matter if it was a one time mistake in a long unblemished career the nurse is now uninsurable.

    I also don't feel it's an admission of anything that the hospital changed it's policy after the error. It's basic risk management, policies are written or re-written any time there is a need for it, good or bad.

    I can't begin to imagine the grief and guilt this nurse felt but choosing to deal with it by ending her own life is exactly that, her choice. The hospital, the BoN and the people who didn't hire her are not to blame for her suicide, she chose to end her life, she chose to inflict additional grief on her family.

    Do nurses honestly think a nurse who causes the death of a patient should get to keep their job?
    If a nurse caused your caused the death of your loved one you want them to keep their job?
    Would you want a nurse who had cause the death of a patient to care for your loved one?
    As a nurse, would you want to share patient care with a nurse who had caused the death of a patient?
    My answer to all 4 questions is no.
    I must say find that sort of attitude rather harsh, especially in this situation where we no nearly nothing as to what caused a nearly 30 year experienced nurse to make a "math error".

    As for keeping nurses on who cause the death of a patient, what about physicans from post graduates to august doctors who cause death. By and large then we hear a different story don't we? What is sauce for the gander is sauce for the goose,that's what I say.

    We all know med dose errors come in several forms, and yes some when they result in death probably do deserve to have a nurse in question discharged and or reported to the state for action. Being as all that may, even when an error does result in a tragic outcome, it does not automatically follow that the nurse is not safe to practice.

    Because nursing staff often administers meds, they are usually on the hook for whatever happens afterwards, even bad decisions by the hospital or whom-ever designed the system and or pharmacy.

    One assumes still covered in every student nurse's med dose calc class, the reconstitution of medications by nursing staff in hospital has changed over the past twenty or so years. As a result by and large much of it is now done via the pharmacy, and not on the floors/units by individual nurses.

    Reconstitution of powdered meds throws an extra wrinkle into the dosage calcuation as one has to dilute properly to obtain the correct amount of medication per unit of measure. If the concentration of solution is incorrect (to strong or too weak) amount given will not equal doctor's orders. A nurse normally working with adults but some how finds herself in peds, may slip and prepare a solution based upon the ratios she is used to working with.

    See:http://qualitysafety.bmj.com/content/15/3/179.abstract

    The above study illustrates just what can go wrong when nurses, even experienced ones deal with reconstituted meds.

    It would be interesting to have known several bits of information regarding this whole tragic incident. What were the doctor's orders? What was the hospital's standards, practice and proceedures for preparing and drawing up sodium chloride for injection and or infusion? What was the infant's condition and diagnosis? Would even the proper dosage as written have had the potential for a very bad outcome? What was going on with the nurse whilst she was making-up the meds? In short everything from the doctor's order to administration should be looked at. We know via published reports Children's came to some agreement with the nurse (but didn't offer to have her back), along with changes to their proccedures after the fact.
    NurseShelly, DeLana_RN, lindarn, and 8 others like this.
  3. 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.
  4. 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.
  5. 3
    So so sad RIP Kim and Kaia
    Mrs. SnowStormRN, lindarn, and nursel56 like this.
  6. 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.
  7. 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!
  8. 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.
  9. 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.
  10. 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.


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