A sobering story-------

WoosahRN, MSN, RN · Nov 29, 2015

That was the first article that mentioned her drawing up the drug. I followed the story when it first happened and there were reports that the order was written incorrectly but also filled by pharmacy incorrectly. That there were other factors and Swiss cheese holes that led to this error. She administered a drug that was wrong but she as the bedside nurse got the discipline (who knows internally what other discipline was done or even if the original info is true).

What happened to her is all our nightmare (and it really could happen to any of us) and she never denied that she made an error. We all do things automatically, thinking we are being cautious, and then have to go back and check or snap ourselves back into focused tasking.

Previous articles mentioned her attempts at trying to find work. Inability to do that with the restriction of not giving meds unsupervised. Her despair and not being able to communicate with her former longtime employer. She was married with kids. And this was a devastating event. She had the integrity to come forward. I can't shake that there were better ways to handle this (not even factoring in the end result of suicide).

If this is how you knew it would be handled would you come forward with an error like this? What about someone else?

AliceTrout · Nov 30, 2015

The order was for 140mg. The drug is supplied in 1gm/10mL vials. The ordered amount would have been 1.4mL. The amount given was 1.4gm, or 14mL. The nurse would have had to open 2 vials to draw up this amount, and would have had to use a 12mL syringe. This would be a big cue to someone experienced in giving CaCl to infants/peds.

I read through all the (somewhat catty?!) replies just to see if anyone else thought this very thing! It was all that went through my mind when I read what happened - how did the massive quantity of this medication not just scream WRONG at this woman who was allegedly used to giving it? I mean even from sheer muscle memory, not even higher level thinking, should have made this error seem obvious to such an experienced nurse, no?

What a sobering reminder of how a brief moment of inattention on our part can have such a ripple effect on patients, families, friends, coworkers, and communities. Remain vigilant friends! :)

Libby1987 · Nov 30, 2015

I'm torn between reading thread upon thread about too much being asked of nurses to the hard line here. From I fear the future of nursing to umpteen other ones decrying nurses being overworked, over faced, lack of patient care priorities versus hotel service and lack of breaks.

I generally have faith that everyone makes the best decision given their choices. I expect that there is way more to this story involving this nurse's competence and capacity. Who knows, maybe she has early onset or something darker. There had to be something that made them escort her out of the hospital.

I don't think it was her shock and beating herself up over the med error so much as being unemployable, but of course that is only conjecture on my part.

It's just horribly sad to see this outcome for someone with a long term stellar record and a family that she had to face.

ETA If the baby hadn't died, would we think differently about this was handled? The outcome of death and how the family feels about it keeps coming up, but I think that's irrelevant to the actions that should be taken. Actions should be based on the breach of protocol and employee assessment/record as well as systems evaluation.

Libby1987 · Nov 30, 2015

Re my comment about yakking, yes we all need to be about to filter out the noise but we don't need to leap from her statement that she was talking to someone to "yakking it up" if we don't know the nature of her distraction.

Susie2310 · Nov 30, 2015

I
Susie2310, I don't see how you've assumed that from my posts (when I've said that at my place of employment, I've witnessed seasoned nurses kill 3 patients in one night due to insulin overdoses for patients who weren't even diabetic!!! And were NOT reported!!!)
I suggest you keep an open mind cause the world isn't always black and white. Leave room for some grey areas and be thankful that in your 20 years no ones ever reported your mistakes.

Your post "HHC Job Search" of Nov 19.

Horseshoe, BSN, RN · Nov 30, 2015

First, I'm not on trial here and administration, and DOH was informed. And I trusted that when my superiors said they would 'handle it' that they would.
secondly,
Correction: One of the patients died directly as a result of the insulin overdose, the other two coded at the same time but were revived.

Ok, well YOU SAID that 3 non diabetic patients DIED in single night at the hands of some apparently rogue nurse giving insulin overdoses. Now it's actually one who died? And 2 additional patients just happened to code later on,but were revived? Okay, then why did you say 3 patients died after being overdosed with insulin? Were these codes directly related to a nurse purposely overdosing them with insulin?

You put this out there and then seem insulted that anyone would question you on them. When you post on a widely read internet forum, you should expect to receive feedback on your posts.

I
Susie2310, I don't see how you've assumed that from my posts (when I've said that at my place of employment, I've witnessed seasoned nurses kill 3 patients in one night due to insulin overdoses for patients who weren't even diabetic!!! And were NOT reported!!!)

CarryThatWeight, BSN · Dec 1, 2015

I
Susie2310, I don't see how you've assumed that from my posts (when I've said that at my place of employment, I've witnessed seasoned nurses kill 3 patients in one night due to insulin overdoses for patients who weren't even diabetic!!! And were NOT reported!!!)
I suggest you keep an open mind cause the world isn't always black and white. Leave room for some grey areas and be thankful that in your 20 years no ones ever reported your mistakes.

I call xx

WoosahRN, MSN, RN · Dec 1, 2015

I call xx.

I'm certainly hoping it's xx. Otherwise Cindy holds some responsibility at seeing someone who committed three sentinel events in one night come back to work. Those actions are definitely enough to raise alarms to police.

WoosahRN, MSN, RN · Dec 1, 2015

I think it's so odd that we still don't have a better way to track licenses and errors from state to state or job to job. This nurse had a solid employee history with no previous errors. While her error was a significant one, it was not done with harm as an intent and she was dealt with harshly (escorted from the property that day?).

And then we have the nurses who are found to be "angels of mercy" or basically serial killers (Charles Cullen) who it turns out had suspicion that surrounded them but their errors were overlooked or the hospitals just covered it by transferring or firing the employee. There usually isn't a surprise about their behavior but rather several people that come forward after the fact that say that they were not good employees or were odd socially or were always on scene for codes. Either it's our culture as nurses to not think the worst or it's an inability to be able to escalate it or that escalation gets squashed. In the case of Charles Cullen (there is an excellent book that just came out about him), it was the police and a cooperating coworker and friend of his, not the hospital, that caught him. He had a string of hospitals that he had been fired from for possible errors, missing medications, even patient's families that reported him for administering meds that weren't for the patient either when he was or even wasn't the assigned nurse.

If this is what being honest about errors gets you, I can see why many would be hesitant to report.

SororAKS, ADN, RN · Dec 1, 2015

Damn. I don't know how to feel about this, except that the medical profession as a whole and hospital corporations have a long way to go in terms of safety and preparedness. Better to proactively assume that errors can and will happen, prepare for them, and make the system as usable and safe as possible rather than assume "good" people won't make mistakes. That does NOT mean I condone mistakes. That means I know they happen. Even practitioners with stellar records make stunning mistakes.

Funny that she had good reviews even recently before the mistake, from the same manager that said she didn't show understanding of what she had done when she made the mistake. I doubt things can change entirely and completely. The manager and likely others are trying to CYA and hung her out to dry. I do also wonder how doctors handle other doctor mistakes and how the Medical Board deals with them. In comparing outcomes with nursing BON disciplines versus those of Medical Boards, usually outcomes are more punitive with nurses. Most don't have attorneys, where doctors generally do. Not that it will bring Ms. Hiatt back, but I wonder what would have happened had it been a doctor?

In retrospect, I'm not sure I would have written a statement in the chart to the extent that Ms. Hiatt did. Had the family decided to sue, their attorney would have had a field day. I don't say that to shame her, just to learn.

RIP Kim Hiatt. I so hated to read this.

SororAKS, ADN, RN · Dec 1, 2015

Another interesting story: Suicide After Medical Error Highlights Importance of Support for Clinicians

weirdscience · Dec 1, 2015

In retrospect, I'm not sure I would have written a statement in the chart to the extent that Ms. Hiatt did. Had the family decided to sue, their attorney would have had a field day. I don't say that to shame her, just to learn.

I got the impression that the statement came from her self-report to the hospital's event reporting system, which does not go into the chart. Not sure how the press got ahold of it, though.