A sobering story-------

[NanikRN]

There but for the mercy of God (or fate, luck, higher power, whatever) go I .......... Or you-----Or you----or even you

Rest in peace Nurse Kim Hiatt

Remembering Kim Hiatt: Casualty of Second Victim Syndrome

[Libby1987]

Yakking it up? With all of the posts on this forum re not enough time to do everything and the constant distractions and interruptions, maybe she wasn't just yakking.

[Rose_Queen, BSN, MSN, RN]

Question: Do they not have a second nurse check all medications that have to be drawn up in all peds? I ask because when my then 4 month old was hospitilzed for RSV last March, he was given meds to open up his airways. One nurse calculated outside the room, drew up, and then a second nurse came in to verify it was correct. First nurse then administered. He only recieved that medication once but I saw the same thing when they gave another baby we were roomed in with a med and both double checked....

That would be dependent upon facility policy or the individual nurses. It's not a requirement of nurse practice acts that I'm aware of (do not live in the state where this happened).

[Susie2310]

To a patient who suffers a serious medication error that results in their serious injury or death, and to their family, whether the mistake is the person committing the error's first, or their ten thousandth, is irrelevant. Also, the fact that an error was unintentional does not change the outcome for the patient or their family, nor does the fact that we are only human and make mistakes. Some people seem surprised that there are often severe career consequences and personal consequences involved for the person that committed the error, and some people appear to think that such consequences are unreasonable/unfair. I am surprised at both of these things, as I learned in nursing school that this was what to expect. As licensed nursing professionals we are held accountable to our patients for the care we provide; my state Nurse Practice Act and associated regulations/statutes spells this out, and our Code of Ethics spells this out.

[cindy_rn456]

Question: Do they not have a second nurse check all medications that have to be drawn up in all peds? I ask because when my then 4 month old was hospitilzed for RSV last March, he was given meds to open up his airways. One nurse calculated outside the room, drew up, and then a second nurse came in to verify it was correct. First nurse then administered. He only recieved that medication once but I saw the same thing when they gave another baby we were roomed in with a med and both double checked....

i only saw this done in nursing clinical and only for certain drugs. This should be standard

[cindy_rn456]

Yakking it up? With all of the posts on this forum re not enough time to do everything and the constant distractions and interruptions, maybe she wasn't just yakking.

Exactly, maybe she was talking to her supervisor, a visitor or the countless other folks who pole to pretend like they don't see the med nurse doing something important.

[CarryThatWeight, BSN]

What I don't understand is how this mistake happened. If she gave this drug all the time, shouldn't she know the amount to draw up? Without even thinking about it? For example, I give Ativan all the time. I know that 1 mg is 0.5 ml. How did she draw up 10 times the amount and not notice that it didn't look right? If the bottle of calcium was a different strength, more concentrated, wouldn't she have noticed that the bottle looked different than usual?

[NursesRmofun, ASN, RN]

Question: Do they not have a second nurse check all medications that have to be drawn up in all peds? I ask because when my then 4 month old was hospitilzed for RSV last March, he was given meds to open up his airways. One nurse calculated outside the room, drew up, and then a second nurse came in to verify it was correct. First nurse then administered. He only recieved that medication once but I saw the same thing when they gave another baby we were roomed in with a med and both double checked....

Great policy to have!

[cindy_rn456]

To a patient who suffers a serious medication error that results in their serious injury or death, and to their family, whether the mistake is the person committing the error's first, or their ten thousandth, is irrelevant. Also, the fact that an error was unintentional does not change the outcome for the patient or their family, nor does the fact that we are only human and make mistakes. Some people seem surprised that there are often severe career consequences and personal consequences involved for the person that committed the error, and some people appear to think that such consequences are unreasonable/unfair. I am surprised at both of these things, as I learned in nursing school that this was what to expect. As licensed nursing professionals we are held accountable to our patients for the care we provide; my state Nurse Practice Act and associated regulations/statutes spells this out, and our Code of Ethics spells this out.

Are you a nurse or nursing student?

[NursesRmofun, ASN, RN]

What I don't understand is how this mistake happened. If she gave this drug all the time, shouldn't she know the amount to draw up? Without even thinking about it? For example, I give Ativan all the time. I know that 1 mg is 0.5 ml. How did she draw up 10 times the amount and not notice that it didn't look right? If the bottle of calcium was a different strength, more concentrated, wouldn't she have noticed that the bottle looked different than usual?

I didn't read anything that said she gave it all the time...but maybe she did. I did read that she was not paying close attention or was distracted with conversation.

[Susie2310]

Are you a nurse or nursing student?

I've been a licensed RN for over 20 years.

[LPNtoRNin2016OH, LPN]

Playing devil's advocate but while I definitely understand being interrupted and how frustrating it can truly be, one could argue that is she had double checked the dosage before giving it then she would have noticed her error if it had been caused by being interrupted while drawing up the med.

[Horseshoe, BSN, RN]

I didn't read anything that said she gave it all the time...but maybe she did.

I messed up,” she wrote. I've been giving CaCI [calcium chloride] for years. I was talking to someone while drawing it up. Miscalculated in my head the correct mls according to the mg/ml.

That was from an article linked later by another poster.

Nurse's suicide highlights twin tragedies of errors - Health - Health care | NBC News