A sobering story-------

Horseshoe, BSN, RN · Nov 28, 2015

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.

Maybe so. Nevertheless, it doesn't make her mistake any less egregious. If someone is trying to talk to you while you draw up an IV drug to give to a small baby, you have to establish your professional boundary. You have to concentrate when drawing up IV meds, and you are supposed to double check your math before giving it, none of which you can do while engaging in any kind of conversation, be it of a professional or personal nature.

dudette10, MSN, RN · Nov 28, 2015

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.

How do you know that the circumstances of the nurse are irrelevant to a patient and their family?

Look, even the laws for criminal charges take into account circumstances of the person charged with a crime. If someone accidentally plowed into my family and killed them all, I would have a very different reaction than if someone intentionally mowed them all down. In both situations they are dead, but my reaction is different. How can you not understand that? Your black-and-white thinking is very disturbing.

Susie2310 · Nov 28, 2015

How do you know that the circumstances of the nurse are irrelevant to a patient and their family?
Look, even the laws for criminal charges take into account circumstances of the person charged with a crime. If someone accidentally plowed into my family and killed them all, I would have a very different reaction than if someone intentionally mowed them all down. In both situations they are dead, but my reaction is different. How can you not understand that? Your black-and-white thinking is very disturbing.

dudette, when I said that whether the mistake is the person's first or their ten thousandth is irrelevant to a patient that has suffered a serious error by a nurse that has resulted in their serious injury or death, by irrelevant I meant that the circumstances of the nurse's error do not alter the fact of the patient's injury or death. If a medication error results in my family member's death or serious injury, the circumstances of the error do not alter the fact of my family member's death or serious injury to my family member, and do not alter the fact of their death or serious injury, to me, their loved one. Is that clear?

Norepinephrine · Nov 28, 2015

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.

Amen!

I do feel a bit badly for this nurse, but I think I would have felt worse for her before last May, when a loved one was seriously injured by a poorly supervised medical intern during a very routine procedure. Sure, it may have been traumatic for the intern, but, and I hate to sound like I'm completely heartless, I don't really care. It was traumatic for my loved one to have emergency surgery, two chest tubes for three months, severe pain, and, worst of all, be unable to breathe. For the first six weeks after the injury it was unclear if my loved one was even going to survive. Couldn't breathe-couldn't walk more than a few yards after having been fit for their entire life. They downplayed it but the pain was horrendous as well. It was a nightmare. I cried more in three months than I have in the past three years. To this day I beg God to protect them, to allow them to fully heal. They're doing much better but they're still not 100%. And the sadness in their eyes-it's like grief for the health they lost. All after a routine day procedure-it was an outcome so rare that two specialists later said that they'd never heard of someone being so badly hurt from this procedure.

I live in fear of making such a mistake, and I'd never forgive myself if I ever did.

It's so much harder to be sympathetic when it's your loved one, when you see someone who means the world to you suffer for weeks and weeks and know that it was preventible. And I think it does take seeing it happen to a loved one-my own health was permanently damaged by a medical mistake, and I've forgiven that even though it was life-altering.

I don't want the responsible parties to harm themselves like Kim Hiatt did. That's tragedy on top of tragedy. But I would be okay with them feeling guilty. They should feel guilty. A lot of neglect was involved, and they caused a lot of suffering.

I know this isn't going to be a popular view on AllNurses. I probably would've thought it was a bit harsh before last May when this event happened. But seeing someone who means a lot to you go through more than anyone else ever should (I left off a LOT of details because it's a pretty unique case, and I want to protect their privacy and mine) changes one's views on this sort of thing I think.

Ruby Vee, BSN · 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.

One of the conclusions that the article seems to draw is that nurses are unforgiving of one another. Yes, it was an enormous med error that may have contributed to the death of an infant (the infant was already quite tenuous), but the nurse made only one error in 25 years. Not a pattern of errors, not a series of errors that contributed to an enormous consequence, but one error. As soon as she made the error, she set about reporting it herself and attempting to mitigate the damage to the patient. She didn't try to cover it up, and she wasn't on this forum wondering about the possible consequences to herself if she did report it. Enormous consequence -- she lost her job, had restrictions on her license and eventually committed suicide.

The system can afford forgiveness for one med error. Or two or three, even, over the course of 25 years. Even big errors like that one. Everyone makes mistakes. Everyone. We all hope that ours aren't as huge or as awful as that one. I'd be less forgiving of someone who had made a series of smaller errors and blew them off.

Ruby Vee, BSN · Nov 28, 2015

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.

I was with you until you brought NETY into it. NETY does not belong in EVERY discussion. But then it got really weird. "Striped of there libidinous and sanity?"

Ruby Vee, BSN · 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.

I think the institution should have considered 25 years with no errors and the nurse should have kept her job. Not all nursing errors are the same, but someone who has made only one error in a quarter century is WAY different from the ones we see on this forum who have made several med errors in one clinical or while on orientation or in six months on the job.

Ruby Vee, BSN · Nov 28, 2015

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.

I don't know what Cindy was suggesting, but I'm suggesting that consequences and career ramifications should be related to one's pattern of errors and not to any one error, no matter how serious. Chronic carelessness is one thing, a single error is quite another.

Horseshoe, BSN, RN · Nov 28, 2015

I'm not sure I believe the part about only one error in 25 years of nursing. It's not particularly relevant, but still, I find it difficult to believe.

Ruby Vee, BSN · Nov 28, 2015

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?

As someone whose family member died as a result of a medical error by their physician, I would definitely think the above scenerio was fair and appropriate. Someone who was habitually careless, flouted procedures or took on a task for which they knew they weren't qualified may be a different story. But someone who made an honest mistake, no matter how serious, should be supported emotionally by their employer, should not face significant career consequences or hardships byond counseling and should return to work in their original -- or a new department -- at their original employer.

People make mistakes. People who make honest mistakes and then immediately set about to mitigate the damage should not be fired, should keep their licenses and should be offered emotional support by their employer.

Ruby Vee, BSN · Nov 28, 2015

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

Speaking for myself and 50-odd cousins, I'd think a great many family members feel that way in those situations.

Ruby Vee, BSN · Nov 28, 2015

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?

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.

We know she was "talking with a co-worker." We don't know she wasn't arranging for someone to cover a break, doublechecking the other nurse's heparin, answering a question from a new grad, or updating the provider on the baby's condition.