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 M/S,DOU/ER.

I did not read the article and made an assumption.Thank you for the correct information.:up:

so sad

Potassium chloride has not been on the floor for years.

Calcium chloride was the drug.

It would seem restrictions on potassium chloride not being on floors is not universal. This occured just a few months ago: http://www.dailymail.co.uk/health/article-1359778/Mother-dies-nurse-administers-TEN-times-prescribed-drug.html

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.....

Math, math, math.

In a large number of these media reported med dose errors you hear the same number "ten" as in "ten times.... dosage given". Math has not changed that much if at all over the past hundred years, and decimals remaining pretty constant. Differences between ones, tenths, and hundredths can have a major impact in the case of a wrong dosage calculation, and be multiplied depending upon method of administration.

Calculators and or computers are only as good as the information entered and the person reading the answer. If the math is wrong going in, you will get the incorrect answer. If you do not know how to "read" and interpet the results, same applies.

Methinks one of the biggest hurdles for nursing students both then and now has to be wrapping their heads around med dose calc, even in this modern age of Dimensional Analysis. Even for students who struggle through, manage to graduate and pass the boards most every hospital and or facility requires a pharma/med exam before hire. Many put the exam before any further interview process (no sense in wasting anyone's time if the applicant cannot get past that part of the hiring process), and passing grades are often >90% if not 100%.

Everyone is demanding perfection in nurses when it comes to meds, but few are thinking about any sort of support or systems to allow a nurse whom has made a "honest" mistake to come forward without fear of punishment. We all learn as children that often owning up to something we have done that was bad can have consequences. Happily (and hopefully) many of us grew up in families where admitting an error did not automatically mean a trip to the wood-shed.

Specializes in PICU.
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?

Not to split hairs here but this doesn't really make sense. Ativan is written in mgs and is a 2mg/mL concentration (in my facility, drawn up from 1ml bottles, and before dilution). So even if he had gotten 2mls it would have been 4mgs which depending on age and wt could have been appropriate (but most likely high-we do 4mgs usually in the older kids-teenagers). But since the desired order was supposed to be 0.2 mls that would have been 0.4mg which is dose I have never given (I think I have seen 1mg as the lowest, maybe, maybe 0.5mg). Also 2 to 0.2 would have been 10 times the amount. I'm thinking 1000x dose of a drug like Ativan would have resulted in respiratory failure. But I'm sure there are just some details mixed up...just wanted to clarify based off the info given.

We do have double checks on majority of meds here in PICU but onbiously errors can still happen. Double checking a med only verifies what was ordered so nurses need to have an idea of what a normal order for that med is. Pharmacy is also supposed to catch this and while we have awesome Peds specific pharmacists, I don't assume that they catch everything. I have to do my own verification as well.

Either way this is just a horrific and sad story. And something that can happen to any of us. So much tragedy on both sides but I am greatly disappointed that the people and company that she dedicated herself to weren't there to help her through it. I cannot imagine the sorrow and guilt she felt, and how alone she must have felt in the aftermath. I am so sad she took her own life.

Specializes in SICU, MICU, CCU.

Truly a twofold tragedy and a blow to everyeone involved.

R.I.P. to Kimberly Hiatt, RN

Specializes in SICU, MICU, CCU.

Hey guys,

I thought you all would appreciate having this article posted. Truly a twofold tragedy and a major blow for all parties involved.

R.I.P. Kimberly Hiatt

http://www.msnbc.msn.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/?GT1=43001%27%20rel=%27nofollow

EDITED by traumarus: Will merge with existing thread.

Specializes in Telemetry.

The most tragic thing about this is that there was no support for her! The statement that the hospital has a "Just Culture" clause that does not seek punitive action for mistakes is bull****. ANY hospital would have made the same decision under these circumstances due to legal issues. I've seen it happen at more than one place of employment. The idea of a just culture makes sense, but it is hardly put into practice. Her family should be able to sue the hospital for not providing a counselor that would come to her house after such an incident and counsel her to make sure she could get through this alive. I've only been a nurse for 3 years and I haven't had any big mistakes like this, but there have been the near misses. I know if something like this had happen to me I would be thinking of commiting suicide, mostly because it takes all the coping mechanisms I have to get through work as it is. This is shamful and nurses across the nation should be OUTRAGED at such negligence on her employer's part!!!!!!

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

From post by DoGoodThenGo:

Everyone is demanding perfection in nurses when it comes to meds, but few are thinking about any sort of support or systems to allow a nurse whom has made a "honest" mistake to come forward without fear of punishment. We all learn as children that often owning up to something we have done that was bad can have consequences. Happily (and hopefully) many of us grew up in families where admitting an error did not automatically mean a trip to the wood-shed...........................I'd like to see a support system set up; you know there are honest mistakes out there and nobody is perfect. This example is an extremely tragic outcome of the problem that is alot more common than we'd like to admit.......................................................................................................................................................................................................................................................

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

UPDATE..................

Do you think she shows enough remorse now?????:devil:

There's some question about whether other factors contributed to Hiatt's firing. Hospital officials said that Hiatt should have recognized that the dose was far too large for such a small child, and that Hiatt violated other dosing protocols. Investigation records show that officials worried that Hiatt didn't fully recognize her role in the error.

"Kim has not shown an understanding of how her deviation from policy in medication administration was in any way responsible for this error," wrote ICU Director Cathie Rea. "Her attention to detail and her precision is not what I would expect it to be at this point in her career."

http://www.msnbc.msn.com/id/43529641/ns/health-health_care/

very sad story

Accidents happen in any field of work. The difference was that this accident caused a death but you also have to keep in mind that medical staff is made out of people and people make mistakes the best thing is to try to avoid making them. But suicide is not the answer.

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