A sobering story-------

Published

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

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.

OMG dudette10!!! Thank you! This is everything I've been saying summed up. Her intention wasn't to kill so why stigmatize her like a murderer???

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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.

Ruby vee, this is exactly my point

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Absolutely agree!!

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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.

We don't know that she made only this one error. The second article, that was more actual reporting than an emotional opinion piece, included statements from the hospital that there was more to the story that could not be disclosed because of privacy concerns, and said that the investigators identified a number of other concerns regarding her practice. As is usually the case here on allnurses, we do not have the full story.

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Then you must work in a utopia

From your posts, I understand you are a new graduate who has not yet found nursing employment. If you have not already done so, I suggest knowing your Nurse Practice Act well. Also know the ANA Nurse's Code of Ethics.

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Specializes in Critical Care.
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.

This whole incident stems from a systems error and it could have been avoided if the hospital provided prefilled syringes with the correct dose, rather than a vial that had the potential to be ten times more than an infant dose! There have been other terrible med errors in the news that likewise could have been avoided if the hospital had only the correct dosage of meds in their ADU. I remember Dennis Quaid twin's overdosage of heparin and the death of a teen mother in Madison WI due to overdose of Magnesium.

These three errors could have all been prevented with proper drug systems! It's ridiculous to expect nurses to draw up meds with vials that could result in such an overdosage in the first place! Secondly given the work environment and all the interruptions nurses face it shouldn't be an option or expectation!

I believe the hospitals and pharmacy dept should be held accountable as well in these situations! They should make the work environment and meds as safe as possible where an overdose would be very difficult if not impossible to occur!

Other pet peeves are having several different concentrations of nitro, heparin, dobutrex or dopamine drips or decided to double concentrate them when the standard was not double concentrated. This is just an accident waiting to happen and the double concentration only compounds an accident! I do believe the computerized med pass and computerized IV pumps help prevent such errors but everything should be made as safe, routine and standardized as possible!

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This whole incident stems from a systems error and it could have been avoided if the hospital provided prefilled syringes with the correct dose, rather than a vial that had the potential to be ten times more than an infant dose! There have been other terrible med errors in the news that likewise could have been avoided if the hospital had only the correct dosage of meds in their ADU. I remember Dennis Quaid twin's overdosage of heparin and the death of a teen mother in Madison WI due to overdose of Magnesium.

These three errors could have all been prevented with proper drug systems! It's ridiculous to expect nurses to draw up meds with vials that could result in such an overdosage in the first place! Secondly given the work environment and all the interruptions nurses face it shouldn't be an option or expectation!

I believe the hospitals and pharmacy dept should be held accountable as well in these situations! They should make the work environment and meds as safe as possible where an overdose would be very difficult if not impossible to occur!

Other pet peeves are having several different concentrations of nitro, heparin, dobutrex or dopamine drips or decided to double concentrate them when the standard was not double concentrated. This is just an accident waiting to happen and the double concentration only compounds an accident! I do believe the computerized med pass and computerized IV pumps help prevent such errors but everything should be made as safe, routine and standardized as possible!

The reporting (which is all any of us here have to go on) says that the hospital had safety systems in place which were considered appropriate by the state investigators. There is no safety system so perfect that errors cannot happen and nurses don't need to be alert and careful. The article also quoted a hospital administrator as saying the nurse had deviated from hospital policy on medication administration. Safety precautions, even the precautions built into computerized MARs and barcode scanning systems, don't keep people safe if nurses ignore or work around them, as I have seen happen many times.

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Specializes in Critical Care.

At least according to someone who's reviewed the entire 1500 page report from the Washington NCQA investigation, there wasn't any sort of pattern of negligence or reckless behavior or even just med errors. Seattle Children's changed various aspects related to med administration related to this incident, so clearly there were some systemic issues that contributed to the error.

As for punishment, I think that needs to be reserved for cases of negligence or intentional harm, or where there is no remorse. This nurse killed herself, I'm not sure it gets more remorseful than that.

https://josephineensign.wordpress.com/tag/seattle-childrens/

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Specializes in Critical Care.
The reporting (which is all any of us here have to go on) says that the hospital had safety systems in place which were considered appropriate by the state investigators. There is no safety system so perfect that errors cannot happen and nurses don't need to be alert and careful. The article also quoted a hospital administrator as saying the nurse had deviated from hospital policy on medication administration. Safety precautions, even the precautions built into computerized MARs and barcode scanning systems, don't keep people safe if nurses ignore or work around them, as I have seen happen many times.

What you are saying is true, the safeguards need to be followed, but again I feel these med errors could have been prevented simply by better hospital med policies. Why would an NICU need adult heparin vials and keep them in the ADU alongside infant doses? This makes no sense to me! This was how the med error involving the Quaid kids happened, an adult vial was grabbed by mistake. On top of this the vials were labeled similarly which lead Dennis Quaid to file a lawsuit against the pharmaceutical company.

The other errors would not have occurred if single use prefilled syringes or volutrols with the appropriate dose were in the ADU. There is no sane reason to have a calcium chloride vial that contained over ten times the expected dose! The teen mom that died in Madison got an overdose I believe because the nurse drew up the wrong amount. You are right that she didn't follow policy and skipped the barcoding process that hopefully would have prevented the error. She also had done back to back shifts with little sleep I believe a 16 hr shift the day before and then made the error the next morning. Criminal charges were even filed against her!

All that aside if only the correct dose was available in the ADU this wouldn't have happened. You haven't made a case to me to explain why this shouldn't be standard practice in all hospital systems.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.
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

I agree. This article is much better written. I couldn't read the one at the beginning of this thread either.

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I

From your posts, I understand you are a new graduate who has not yet found nursing employment. If you have not already done so, I suggest knowing your Nurse Practice Act well. Also know the ANA Nurse's Code of Ethics.

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.

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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.

Did you do anything to prevent or report these alleged errors? Call out the nurse doing it, repot to the charge or manager, use a pt safety line? If not, why? Imho, if you did not, you are complicit I the errors AND a huge part of the cult of silence that enables med errors to go unaddressed.

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