Nurse suicide follows infant tragedy

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The suicide of a nurse who accidentally gave an infant a fatal overdose last year at Seattle Children's hospital has closed an investigation but opened wounds for her friends and family members, as they struggle to comprehend a second tragedy.

Kimberly Hiatt, 50, a longtime critical-care nurse at Children's, took her own life April 3. As a result, the state's Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant's death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt's mother.

"She absolutely adored her job" at Children's, where she had worked for about 27 years, said Crum. "It broke her heart when she was dismissed ... She cried for two solid weeks. Not just that she lost her job, but that she lost a child."

continued: http://seattletimes.nwsource.com/html/localnews/2014830569_nurse21m.html

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

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
they pulled protocols and reviewed them and deemed their protocols to not be at fault, which resulted in the nurse to have pointed fingers at her.

Not true...it was brought up that the policies WERE found insufficient and subsequently changed. BUt someone had to be "blamed". :( Hence enter the nurse

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I'm about to start nursing school in a couple of months and I cannot tell you how much this story terrifies me. Especially since I want to work with pediatric cardiac patients and I know the medications they are prescribed are extremely potent and volatile. I personally have a friend whose son was given 1,000 times the amount of Ativan he was supposed to be given and thankfully just slept for an extra 12 hours, but still awfully scary! The resident had written the RX wrong 2 mls instead of .2 and the pharmacy didn't catch it, nor did 2 nurses who double-checked it per hospital protocol.

I have been thinking about this story a lot the last two weeks. Anybody have any words of encouragement on how to make sure this doesn't happen?

This is an everyday potential in nursing practice. A very healthy dose of fear of making a mistake will go a long way to to help keep you from making one. But there are some things to remember no matter how busy you are....

1) Never ASSUME (assume stands for "A** of U and ME") that the dosage is right....No matter who ordered it of filled it or calculated it...check it yourself.....check everything....recalculate everything.....KNOW what and why you are giving anything.

2) Especially with children.......WATCH Kilograms to pounds and pounds to kilograms.....WATCH YOUR CONVERSIONS CAREFULLY!!!! The slight movement of a decimal point can have FATAL outcomes.

3) Find a dosage caculation app or web site. Use 2 different methods and people to check calculations. It's a pain in the butt......but worth it's weight in gold.....ask another nurse to check your math. Annoying but vital!

4) If it seems too much or too large....it probably is....listen to your inner voice......if it seems wrong it probably is.....trust your inner "Oh! Oh" voice....

5) Always use a calulator....even if you know the answer....check again......refer to number 3. Just like Santa check it twice!!!!!

6) Don't freak out......use your brain. Take your own pulse first....pay attention. Deep breathe.

7) And prayer........Always as God for a little help everyday......

I hope this helps.....

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

And if you make a mistake....tell someone immediately!!!!

And if you make a mistake...don't repeat it and forgive yourself....xo

Specializes in Med nurse in med-surg., float, HH, and PDN.

There but for the grace of God......Am Praying for both souls and both families. What a terrible tragedy for all.....

I have been thinking about this story a lot the last two weeks. Anybody have any words of encouragement on how to make sure this doesn't happen?

Be careful and pray.

Specializes in Med/Surg.

I don't understand why they threw this woman under the bus. It could happen to any nurse so when I read this it really broke my heart.

Here are two links to the original story (infant's overdose) at that time:

http://www.komonews.com/news/local/103907864.html

and:

http://www.king5.com/news/local/Infant-death-from-overdose-raises-questions-at-Seattle-Childrens-103970878.html

IMHO nurse Hiatt happened to make her error at the wrong time for it to occur at Children's.

With another major and widely covered by local media med dose error by the nursing staff just a year prior, and about 18 "adverse" reactions reported to the state since 2006, the hospital (and or it's legal counsel) probably felt a line had to be drawn in the sand.

The attorney who got a settlement from Children's in the matter of the boy who died 18 months prior due to a med error was already in the media pretty much saying the place cannot be trusted, and as proof yet another child has been harmed by the nursing service. The DON (or whatever she or he in charge of the nursing service at Children's is titled) could have gone down on bended knee and it probably wouldn't have made a bit of difference.

Back in the day a nurse who made an error, even a major one might be transferred, sent on vacation, anything to lay low for awhile, then when things cooled brought back. Of course this depended upon the nurse in question work record, but am willing to bet at near 30 year experienced RN, with an otherwise spotless record wouldn't have been shown the door.

Insurance companies and attorneys have great sway on hospitals. As far as either are concerned nurses are easily replaced, but the liablilty of a "bad" nurse is just too great of a risk.

A little more about nurse Hiatt from a local news article:

http://www.nwcn.com/home/?fId=121003144&fPath=/news/local&fDomain=10212

they pulled protocols and reviewed them and deemed their protocols to not be at fault, which resulted in the nurse to have pointed fingers at her.

State investigated both this and two other adverse incidents and cleared Children's in all three cases.

http://www.nwcn.com/news/washington/Dept-of-Health-finds-no-deficiencies-in-Seattle-Childrens-systems-107065683.html

To err is human... we are all fallible, no one is excepted. So why are nurses held to such an impossible standard that even doctors are not expected to meet, i.e. perfection? Hospital doctors - interns, residents, and attendings as well - make serious and fatal mistakes, and it is discussed in their M & M conferences as a learning experience. For nurses, however, there is zero tolerance - they are expected to be perfect, and if the odds finally catch up with them (in this case, after 27 years of flawless performance!) they are harshly dealt with, usually fired (and, it goes without saying, basically no longer employable in their chosen profession).

You cannot prevent humans from making mistakes (in unsupportive environments, they will most likely cover them up, giving punitive employers the illusion that mistakes don't occur). One example is a hospital I used to work for. They have a punitive policy for, among other things, lab errors (such as sending the wrong pt's sample, which is caught when the lab notices unlikely results, or sending a tube with Pt A's name and Pt B's requision). The current - ever harsher - policy includes a mandatory 3-day suspension and notice of impending termination if it happens again; it doesn't get much worse than that. So there shouldn't be any lab errors now, wouldn't you think? Wrong. They have basically not decreased since the first, more lenient policy, was instituted (as I know from a friend who still works there). They could probably fire (or maybe shoot?) the guilty parties on the spot, and there would still be lab errors! Because humans are human, and therefore fallible. In fact, I believe that with ever-harsher punishments you reach a point of diminishing returns where the fear of consequences and the resulting stress causes workers to be more likely to make mistakes!

My heart goes out to the families of this nurse and the infant who died. It's truly tragic.

DeLana

Specializes in M/S,DOU/ER.

This is a tragic example of why potassium chloride should not be within reach of any nurse or Dr. on any floor but especially on a pediatric unit.It seems that someone always has to be injured or killed before any type of reform takes place and if the potassium had not been on the floor I would not be writing this.There is plenty of blame to go around.:confused:Im so sorry for the families of the pt.and nurse.

This is a tragic example of why potassium chloride should not be within reach of any nurse or Dr. on any floor but especially on a pediatric unit.It seems that someone always has to be injured or killed before any type of reform takes place and if the potassium had not been on the floor I would not be writing this.There is plenty of blame to go around.:confused:Im so sorry for the families of the pt.and nurse.

Potassium chloride has not been on the floor for years.

Calcium chloride was the drug.

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