A sobering story-------

elkpark · Nov 28, 2015

I read the article. It is a sobering story, but I'm not sure what conclusions I am supposed to draw from it (it's also kind of weird to read the v. serious, rather melodramatic article, and then the little blurb at the bottom from the author about she has "restless feet" and is always on the hunt for the best cheesecake ...) The article makes the usual argument about how healthcare should be more forgiving of nurses' errors and not stigmatize nurses for making them, but the nurse featured in the article accidentally gave 10 times the ordered dose of a serious medication to a critically ill small child who died a few days later. I'm sorry that the nurse involved eventually chose to commit suicide, but, at the same time, how much forgiveness can the system afford? How much of a margin of error is acceptable? People who are sick and vulnerable are counting on all of us to get things right. I wonder how the author of the article would feel if it were her child who had received the overdose.

cindy_rn456 · Nov 28, 2015

I read the article. It is a sobering story, but I'm not sure what conclusions I am supposed to draw from it (it's also kind of weird to read the v. serious, rather melodramatic article, and then the little blurb at the bottom from the author about she has "restless feet" and is always on the hunt for the best cheesecake ...) The article makes the usual argument about how healthcare should be more forgiving of nurses' errors and not stigmatize nurses for making them, but the nurse featured in the article accidentally gave 10 times the ordered dose of a serious medication to a critically ill small child who died a few days later. I'm sorry that the nurse involved eventually chose to commit suicide, but, at the same time, how much forgiveness can the system afford? How much of a margin of error is acceptable? People who are sick and vulnerable are counting on all of us to get things right. I wonder how the author of the article would feel if it were her child who had received the overdose.

Tones like this are what make it so hard for nurses to come forward after a mistake and openly admit it without everyone judging. Once a mistake is made don't you think we beat ourselves up enough without outside scrutiny? This article is so relevant! The amount of pressure (sanctions on your license or jail time or costly lawsuits) put on you for one mistake. There are cops out here killing people for nothing and walking away scotch free, but nurses are held accountable for being human and making mistakes?? This just shows the problem with our thinking and the system. No matter how good of a nurse you are all that suddenly goes away because you made a mistake and now you must wear the scarlet letter (no future employment as a nurse)?? She felt bad enough for the manslaughter of the child so much so that she took her own...smh

NanikRN · Nov 28, 2015

I read the article. It is a sobering story, but I'm not sure what conclusions I am supposed to draw from it (it's also kind of weird to read the v. serious, rather melodramatic article, and then the little blurb at the bottom from the author about she has "restless feet" and is always on the hunt for the best cheesecake ...) The article makes the usual argument about how healthcare should be more forgiving of nurses' errors and not stigmatize nurses for making them, but the nurse featured in the article accidentally gave 10 times the ordered dose of a serious medication to a critically ill small child who died a few days later. I'm sorry that the nurse involved eventually chose to commit suicide, but, at the same time, how much forgiveness can the system afford? How much of a margin of error is acceptable? People who are sick and vulnerable are counting on all of us to get things right. I wonder how the author of the article would feel if it were her child who had received the overdose.

I don't know that there are specific conclusions that any one was supposed to draw. Certainly there's no dispute that it was a critical and avoidable error even if it wasn't determined how much the error contributed to the child's death

I didn't get the impression it was about making it all right for that nurse. She had severe sanctions placed on her license /ability to give meds and rightly so.

I got more of impression that it was more about how stigmitized she was-- how isolated.

Sometimes we do that to prove to ourself how much we are not like that person, how it could never happen to us, that we are safe from that happening to us.

None of above is meant to be targeted to you, Elkpark, or anyone else. Just my musings----

And i totally missed the cheescake blurb. That IS weird.

Susie2310 · Nov 28, 2015

I read the article. It is a sobering story, but I'm not sure what conclusions I am supposed to draw from it (it's also kind of weird to read the v. serious, rather melodramatic article, and then the little blurb at the bottom from the author about she has "restless feet" and is always on the hunt for the best cheesecake ...) The article makes the usual argument about how healthcare should be more forgiving of nurses' errors and not stigmatize nurses for making them, but the nurse featured in the article accidentally gave 10 times the ordered dose of a serious medication to a critically ill small child who died a few days later. I'm sorry that the nurse involved eventually chose to commit suicide, but, at the same time, how much forgiveness can the system afford? How much of a margin of error is acceptable? People who are sick and vulnerable are counting on all of us to get things right. I wonder how the author of the article would feel if it were her child who had received the overdose.

My response was similar to yours.

MunoRN, RN · Nov 28, 2015

There's a pretty well proven principle that punitive action against med errors increases future risk of med errors, not decreases them. All punitive action does is encourage other nurses to avoid reporting errors and near misses which means the causes won't be addressed and they'll just keep happening.

cindy_rn456 · Nov 28, 2015

There's a pretty well proven principle that punitive action against med errors increases future risk of med errors, not decreases them. All punitive action does is encourage other nurses to avoid reporting errors and near misses which means the causes won't be addressed and they'll just keep happening.

my point exactly!! It could have been anyone. She was a 25 year veteran and it happened to her. (That should be a lesson to all the 'nurses who like to eat their young'). New grads are the only ones who make mistakes. It could have been any of us. Although there should be a matching consequences I don't think nurses should automatically striped of their libidinous and sanity. We're human beings and life can happen.

elkpark · Nov 28, 2015

Tones like this are what make it so hard for nurses to come forward after a mistake and openly admit it without everyone judging. Once a mistake is made don't you think we beat ourselves up enough without outside scrutiny? This article is so relevant! The amount of pressure (sanctions on your license or jail time or costly lawsuits) put on you for one mistake. There are cops out here killing people for nothing and walking away scotch free, but nurses are held accountable for being human and making mistakes?? This just shows the problem with our thinking and the system. No matter how good of a nurse you are all that suddenly goes away because you made a mistake and now you must wear the scarlet letter (no future employment as a nurse)?? She felt bad enough for the manslaughter of the child so much so that she took her own...smh

I didn't mean to have a "tone." I sincerely struggle with this question. Yes, we are all human, and, yes, we all make mistakes. But where is a line appropriately drawn between supporting nurses and not minding that mistakes get made? Lots of nurses do make mistakes and don't suffer any serious consequences from their employers or the BON, and go on with their careers successfully. But this situation (in the article) involved a particularly egregious error, and a child died. Is the organization supposed to say, "That's okay, we don't mind"? Are you suggesting that all nursing errors are the same? That there is no error serious enough that a nurse should suffer serious consequences?

Nothing in the article suggested that this nurse was facing "no future employment as a nurse." She kept her license; she was put on probation with limitations on her practice similar to those put on nurses in impaired professionals programs. The article notes she was having difficulty finding another job, which is understandable under the circumstances and similar to the difficult road faced (and overcome) by many nurses coming back from a drug/alcohol problem, but there was no indication she wasn't going to be allowed to continue with her career.

I am all about supporting other nurses, and I feel bad about this nurse having chosen to end her life rather than getting some help and working through the situation; I just don't think it's realistic to say that no one should ever have to suffer consequences for an error.

cindy_rn456 · Nov 28, 2015

I didn't mean to have a "tone." I sincerely struggle with this question. Yes, we are all human, and, yes, we all make mistakes. But where is a line appropriately drawn between supporting nurses and not minding that mistakes get made? Lots of nurses do make mistakes and don't suffer any serious consequences from their employers or the BON, and go on with their careers successfully. But this situation (in the article) involved a particularly egregious error, and a child died. Is the organization supposed to say, "That's okay, we don't mind"? Are you suggesting that all nursing errors are the same? That there is no error serious enough that a nurse should suffer serious consequences?
Nothing in the article suggested that this nurse was facing "no future employment as a nurse." She kept her license; she was put on probation with limitations on her practice similar to those put on nurses in impaired professionals programs. The article notes she was having difficulty finding another job, which is understandable under the circumstances and similar to the difficult road faced (and overcome) by many nurses coming back from a drug/alcohol problem, but there was no indication she wasn't going to be allowed to continue with her career.
I am all about supporting other nurses, and I feel bad about this nurse having chosen to end her life rather than getting some help and working through the situation; I just don't think it's realistic to say that no one should ever have to suffer consequences for an error.

Understood. Please know that this isn't at all a personal criticism of your view, I just feel that unfortunately this is how the nursing system has trained us (everyone for him/herself or 'just be glad it wasn't you'). I feel we should be more supportive of each other. And I agree that the punishment should fit the crime because I've seen nurses kill several patients throughout their career and gone unreported and unsactioned smh (administration even covered up for them) after patterns of infarction sugar resulted in people dying.

My my point is even if she's technically 'allowed to keep her license', who will hire her knowing what she was sanctioned for?? It's pretty much the death of her career. HR would eventually overlook her application even if she rectified herself and learned her lesson. Why waste time with explanations when there are plenty of other qualified nurses without infarctions on their license to choose from??

allnurses Guide · Nov 28, 2015

I read the article. It is a sobering story, but I'm not sure what conclusions I am supposed to draw from it (it's also kind of weird to read the v. serious, rather melodramatic article, and then the little blurb at the bottom from the author about she has "restless feet" and is always on the hunt for the best cheesecake ...)

I missed that part. Every blog has a little blurb about the blogger. (Try to say that 10 times fast).

Oh and she had "rootless" feet.

I agree with your concerns regarding medical mistakes.

But I know if I had done this, I probably would stop being a nurse all together and can understand her choice as well.

Not condoning it. Just understand it.

This is a good conversation to have but I'll bow out for now as I'm being called in another direction.

Susie2310 · Nov 28, 2015

Understood. Please know that this isn't at all a personal criticism of your view, I just feel that unfortunately this is how the nursing system has trained us (everyone for him/herself or 'just be glad it wasn't you'). I feel we should be more supportive of each other. And I agree that the punishment should fit the crime because I've seen nurses kill several patients throughout their career and gone unreported and unsactioned smh (administration even covered up for them) after patterns of infarction sugar resulted in people dying.
My my point is even if she's technically 'allowed to keep her license', who will hire her knowing what she was sanctioned for?? It's pretty much the death of her career. HR would eventually overlook her application even if she rectified herself and learned her lesson. Why waste time with explanations when there are plenty of other qualified nurses without infarctions on their license to choose from??

My response is similar to Elkpark's. I am sympathetic, because, yes, we all make mistakes, but I ask, are you suggesting that there should be no career ramifications in these types of situations? That in spite of having been able to keep one's license, one should not face any difficulty finding another job? Keeping one's license and being put on probation means that one was supported by one's BON if one is a nurse, or state Medical Board if one is a doctor. You seem to be suggesting that one should face no consequences or hardships as a result of a serious error that contributes to or results in a patient death. Life isn't like that. The career consequences are consequences I would expect under similar circumstances, and I would consider them fair.

elkpark · Nov 28, 2015

My my point is even if she's technically 'allowed to keep her license', who will hire her knowing what she was sanctioned for?? It's pretty much the death of her career. HR would eventually overlook her application even if she rectified herself and learned her lesson. Why waste time with explanations when there are plenty of other qualified nurses without infarctions on their license to choose from??

You're right that she would have had an uphill struggle continuing her career, but I don't think that's an issue of nurses not supporting nurses. Someone who has made that serious an error (esp. made it recently) is a liability risk for employers, a risk that a lot of employers are not willing to take. Every nurse who works for an organization could advocate for that nurse being hired, and the attorneys and financial people would overrule them. That's reality. The same is true of lots of other nurses who have had drug or alcohol problems, or have made other kinds of nursing errors and ended up with probation and stipulations on licenses, but many of them have persevered and jumped through the hoops required of them and continued on with their careers. There are tons of people posting in the recovery forum here who have done it, and I've worked with a few nurses over the years who lost their licenses because of egregious errors (one involved a death) and yet got their licenses back and were able, over time, to resume and continue their careers. I would not assume that this incident would have been the "death of her career." Would she have had a long, difficult path ahead of her? Yes. Would that be unjustified under the circumstances? I don't know the answer to that question. No one will ever know how things might have worked out for her over time, but there is lots of evidence to suggest that she would likely have been able to continue in nursing.