A sobering story-------

brownbook · Nov 28, 2015

How errors should be dealt with.

Editorial Team / Admin · 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

Not every med error is a systems issue. From the sounds of it (talking while drawing up a med), this was truly a case of the nurse not paying appropriate attention to what she was doing. Yes, there should be outside scrutiny- this was a serious error that resulted in death. This was not an error where it was simply monitor the patient for adverse effects. Yes, the BON should have been involved. Yes, there should have been an investigation. The results of that investigation should have determined whether there were sanctions on her license, further education required, etc. Just because "there are cops out here killing people for nothing and walking away scotch free" (and that's debatable and definitely not the majority of officer involved shootings- after all, we only hear about the controversial ones) has nothing to do with this scenario.

allnurses Guide · Nov 28, 2015

This article is so poorly written that I couldn't force myself to read the entire thing.
Much better article here:
Nurse's suicide highlights twin tragedies of errors - Health - Health care | NBC News

Thanks for that. As elkpark mentioned, a much better representation of the facts and not emotion. Although, this is an emotional issue as well. I'd really like to have seen the protocol for giving this medication as the article states the safeguards were already in place but they increased safeguards.

Medical errors are huge unfortunately and yes, we do need to continue to look at safeguards. About the time I became a nurse, the standard changed regarding medical errors from punitive to education. In order to find the problems, we needed to make medical folks feel safe about reporting, so we could fix them. Obviously if the error leads to injury or death, then that has to be looked at in the legal system. (One reason everyone should have a private malpractice insurance policy by the way).

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 don't think comparing cops and nurses have anything to do with one another in this thread.

And cops in general are not getting away "scotch free" (not the real term) or "scot free" (the real term).

The Term "Scot Free" Does Not Come from the Dred Scott v. Sandford Supreme Court Case

Susie2310 · Nov 28, 2015

How errors should be dealt with.

It appears you are saying that a nurse who makes a serious error that contributes to or results in a patient death should be supported emotionally by their employer, and should not face any significant career consequences or hardships beyond counseling, and should eventually return to work in a new department at their original employer.

If your family member died as a result of a medication error by their nurse, would you think this is fair and appropriate?

brownbook · Nov 28, 2015

Yes I would.

ambr46 · Nov 28, 2015

This is a good reminder to always double check dosage calculations with another nurse especially when dealing with infants and children.

What a truly terrible event.

Susie2310 · Nov 28, 2015

Yes I would.

How do you think family members usually feel in these kinds of situations?

Horseshoe, BSN, RN · Nov 28, 2015

I think most parents would say that there is no one they love more than their children. If a nurse made a fatal med error which led to the death of my child, and I learned that she was yakking it up with a coworker while drawing up an IV medication, I would be beyond livid.In this scenario, we are not talking about meds which are in near identical containers, a piggy back incorrectly mixed by pharmacy, meds which have similar and easy to confuse names, or any other number of "system" problems. What we had was a nurse who was distracted and not paying attention. So unfortunate for all involved, but ultimately that is a clear case of nurse error.

dudette10, MSN, RN · Nov 28, 2015

How do you think family members usually feel in these kinds of situations?

The article states that the baby's family asked that Hiatt not care for the child anymore, but that no one should be severely punished for it. The Quaids didn't want the nurse who overdosed one of their twins on heparin to be burned at the stake either.

You assume that all families want the severest punishment possible. That is just not the case.

I am aware of a case in which a nurse not only willingly and repeatedly did not give medications, but also documented that she did give them, then she lied to the patient about it. It was eventually discovered, and the nurse was going to get a warning, but the family insisted on firing, which did happen. However, the family purposely did not report to the BON, and strangely enough, neither did the facility. This is just another example of families who are not out for blood, although I tried to convince the family that the nurse did deserve to have her license permanently revoked.

So you've got willfull actions vs accidents. Willful acts and omissions do indeed happen. We should save our severest punishments for those nurses.

NanikRN · Nov 28, 2015

A child dies, lives are saved.
An experienced nurse miscalculated a medication dose resulting in the death of an 8 month old child.
The nurse immediately reported the mistake. The events leading up to the mistake were analyzed while fresh in her mind. She was then escorted to a counselor for support and therapy. Mandatory weekly appts were arranged with the counselor. She was placed on admimstrative leave. She returned to part time work in the education dept.teaching a class on medication errors. Eventually she returned to full time work in a different department.

I think action plans like this are the missing piece of the equation. Image the impact her story would make on nurses- both experienced and new! A horrific medical situation is how Condition H came about in hospitals- remember that little girls story?

And I'm not advocating for lack of consequences--of course there should be appropiate sanctions. I believe there's room for both consequences and compassionate follow through in the equation

Edited to add link to Josie's story

What Josie King's story should teach us | NJ.com

dirtyhippiegirl, BSN, RN · Nov 28, 2015

I don't know if the desire to punish one nurse for his or her actions outweighs the fact that it is well-established by research that treating errors in a punitive fashion causes nurses to misreport and underreport their own errors?

If OP's link is right about her licensing stipulations and not being able to ever pass meds without another nurse present -- those are WAY worse then your usual monitoring contract stips and would have made it impossible to work in most of the environments that are monitoring program friendly.

Susie2310 · Nov 28, 2015

The article states that the baby's family asked that Hiatt not care for the child anymore, but that no one should be severely punished for it. The Quaids didn't want the nurse who overdosed one of their twins on heparin to be burned at the stake either.
You assume that all families want the severest punishment possible. That is just not the case.
I am aware of a case in which a nurse not only willingly and repeatedly did not give medications, but also documented that she did give them, then she lied to the patient about it. It was eventually discovered, and the nurse was going to get a warning, but the family insisted on firing, which did happen. However, the family purposely did not report to the BON, and strangely enough, neither did the facility. This is just another example of families who are not out for blood, although I tried to convince the family that the nurse did deserve to have her license permanently revoked.
So you've got willfull actions vs accidents. Willful acts and omissions do indeed happen. We should save our severest punishments for those nurses.

Please do not put words into my mouth. I asked "How do family members usually feel in these kinds of situations?" in response to Brownbook's comment about how he/she thought medication errors should be dealt with. I have made no assumptions whatsoever about family members. My reply was a general one that encompassed serious errors made by nurses that result in patient deaths.