Nurse suicide follows infant tragedy

[babyNP.]

The suicide of a nurse who accidentally gave an infant a fatal overdose last year at Seattle Children's hospital has closed an investigation but opened wounds for her friends and family members, as they struggle to comprehend a second tragedy.

Kimberly Hiatt, 50, a longtime critical-care nurse at Children's, took her own life April 3. As a result, the state's Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant's death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt's mother.

"She absolutely adored her job" at Children's, where she had worked for about 27 years, said Crum. "It broke her heart when she was dismissed ... She cried for two solid weeks. Not just that she lost her job, but that she lost a child."

continued: http://seattletimes.nwsource.com/html/localnews/2014830569_nurse21m.html

How horrible for everyone in the situation...she had worked at Seattle Children's for 27 years, the article states.

[LTCangel, ADN, BSN, LPN]

This all so sad for both families. I cannot understand why this nurse was thrown under the bus, 27 years is a long history of nursing experience and loyalty to this hospital. The hospital had every right to discipline her and so did the BON, but the harshness that was shown to her will cause other nurses to be afraid to report their mistakes and try to cover them up. We were all taught to self report any errors and that it would not cause us to be fired, disciplined or educated but not fired. Each and every nurse no matter what type of nursing they do are having to take care of increasingly larger amount of patients and mistakes are almost inevitable. Seems the hospitals and any other medical facility are deciding to always discard the nurse because at this time in many areas there are 50 more waiting for a job. All of this could have been handled in a better way. So sad.

[DoGoodThenGo]

How horrible and so very sad!

This is what comes from nurses being thrown under a bus and or demonised by the public, media and everyone else after a tragic outcome due to an error. Well now all those screaming at the time (I too remember the original story), have gotten their pound of flesh.

Pace, pace Kim. Though you've answered the last call bell, you are now in a place where your entire life's work will be weighed in the balance. *RIP*

[MrAllenU]

Perhaps the hospital could have offered her counseling rather than just dismissing her. They would have to know that such a tragedy would undoubtedly cause much psychological and emotional stress for such an experienced nurse.

It's a good thing that great nurse nor her work will not be forgotten.

[Batman25]

This poor woman dedicated more than half of her life to nursing. She worked with babies and children the entire time for the same employer. 27 years she dedicated to her profession, employer, and the children. One error and she was under the bus. I hope those that didn't offer a helping hand or a kind word to this woman in obvious distress can sleep well at night. Shame on them.

[casper1]

So sad a terrible mistake that took 2 lives.

I have to say that as nurses we face constant distractions as we try to provide care. How many times have other nurses, techs ,patients familiy members, patients, doctors interupted us as we prepare medications, write verbal orders. Nurses need to be provided with a quiet isolated area where medications can be prepared and then brought to the patient.

[Bella'sMyBaby]

Such a tragedy...

Is it REALLY worth it all to have a job with so much responsibility?

The stress is just too much.

[NicuGal, MSN, RN]

This is incredibly sad This poor woman was thrown under the bus. And they wonder why people don't report med errors!

We no longer are able to draw up any of our own meds, except for a select few like versed, fentanyl and morphine. The pharmacy does it for us, or they are in doses in the pyxis.

Rest in peace now

[Esme12, ASN, BSN, RN]

I have said so many times here that a nurse is responsible for all her actions. That no one will protect you but you...... The hospital, the doctors, your peers, your friends from work will ignore you feed you to the wolves and all will throw you under the bus to save themselves and make you the corrective action........This is the one in a hundred times you MUST have malpractice insurance so that when you are short staffed, over worked, and you make that one mistake and your worse nightmare comes true and someone dies:eek:........you at least have a lawyer in your corner.

My heart breaks for the family of the infant and although I do not know the details......anyone who works one place for 27 years is NOT a sloucher or a liability. I feel heart breakingly sad for the nurse who had everything stripped from her and made her have nothing to live for........I cry for our loss of such an example of a nurse who cared for those who are ill for one hopsital for 27 years.......I cry that she died heartbroken and riddled with regret. How sad she died watching everything she had ever done or worked for destroyed.......including her honor and her good name.

Shame on the hospital who sent her down the river or those who did not come to rescue her from her grief. I pray for her family and the child's family to find peace.............

But for the Grace of GOD go I..........

[wooh, BSN, RN]

The hospital had every right to discipline her and so did the BON, but the harshness that was shown to her will cause other nurses to be afraid to report their mistakes and try to cover them up.

Exactly.

She practiced for TWENTY SEVEN years. If she was truly dangerous, I'd think it would have shown up before now.

There is NOBODY that is perfect. This was a tragic mistake. Throwing this nurse under the bus made it even more tragic.

[Old.Timer]

i think we, as nurses, have an opportunity to provide at least a small measure of value and meaning to this horribly tragic event.

we each should encourage formal discussion of this case within our organization's performance improvement, patient safety or similar committees etc. in addition to discipline, that is within the context of the nurse's previous history, provisions need to be in place to provide support and counseling to nurses experiencing traumatic errors.

as nurses are expected to take care of increasingly larger number of patients, the occurrence of medication errors will also increase. errors should serve as a red flag for systems and process review, not immediate staff termination.

ideally, this event will prompt review and establish protocols for the manner in which nursing medication errors are handled. just as the libby zion case and her death, was the catalyst for sweeping change within medical residency programs, perhaps the lives of kimberly hiatt and kaia can serve a similar noble purpose.

nursing is notorious for taking care of others.

we ignore our own.

that must change.

this is every nurse's nightmare come true.

[wooh, BSN, RN]

nursing is notorious for taking care of others.

we ignore our own.

that must change.

this is every nurse's nightmare come true.

totally agree.

[j450n, BSN, MSN, RN]

This is heartbreaking and just an overall tragic ending to an unfortunate event. I will actually have my peds rotations at the same facility and I'm honestly a bit apprehensive. I definitely have a great respect for peds nurses...it's one thing to already work with the vulnerable, young patient demographic and overbearing parents, but the ramifications of a medication error are huge.

Here's some letters to the editors regarding the event:

Also found at: http://seattletimes.nwsource.com/html/northwestvoices/2014847389_suicideofnurseaftertragicevent.html

Suicide of nurse after tragic event

Posted by Letters editor

We all make mistakes

I have followed your stories regarding the death of the infant at Seattle Children's Hospital last year due to an overdose of calcium chloride. With the story Thursday and its additional facts, I find that my level of frustration is markedly increased ["Nurse's suicide follows tragedy," NWThursday, April 21].

One of the well-accepted principles of error management in medicine today is that mistakes are mostly commonly the result of system problems, not mere negligence on the part of the provider.

With the case at hand, my first concern is that I am hard-pressed to think of a reason that I would prescribe calcium chloride for an infant when the drug was to be administered by a solo nurse in a nonemergency situation. Second, calcium chloride is a dangerous drug and when used in infants, its dose should be double checked by the pharmacy staff.

The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error.

In addition, I am at a loss to see how a fine, levied by the state disciplinary authorities, is even a help to the infant's family, the public or the nursing profession.

If we fire every person in medicine who makes an error, we will soon have no providers. We all make errors. It is only by the grace of God that most of them do not result in great harm or death.

It is my belief that if the nurse had been dealt with appropriately- with compassion and insight-that she, today, would be a valuable and happy nurse. But she was fired.

I, in no way, want to minimize the tragedy of the death of this infant, however, the death of Kimberly Hiatt is no less tragic.

-- F. Norman Hamilton (retired anesthesiologist), Seattle

Change the system

The Times' story, "Nurse's suicide follows tragedy," illuminates an Achilles' heel in America-the safety of our children.

In the face of a threat or in response to the tragic loss of a child, communities come together to punish the perpetrator. In this case, a veteran pediatric nurse was fired when a medication error resulted in the loss of a child. Heartbreaking as this is, the rush to punish Kimberly Hiatt feels reactionary at best.

As a student nurse currently in my pediatric rotation, I am bewildered by the 4-1 patient to nurse ratio in hospitals. The children I work with receive medications that can cause anaphylactic reactions at any point during their infusions.

With three other patients to juggle, the nurses I shadow cannot continuously monitor for signs of reaction. The nurses are forced to gamble, hoping the child does not have a reaction.

Are parents aware of the risk they take when walking through the doors of their hospital? I dream of the day when parents lead the way for upstream change in health care demanding universal and adequate coverage of our children versus punishing the nurses that do their best within a broken system.

When will we stop turning a blind eye and realize that until we change the system, we are the perpetrators responsible for failing our children and our society?

-- Leesa Benenhaley, San Francisco, Calif.