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]

kids I pray YOU never ever make a mistake. And if you do I hope that you will be able to handle all of the associated fallout.

[kcmylorn]

What a stinking shame. I think this is one more example of the how much is wrong with our profession. There are NO mechanisms in place to help the nurse- only if the nurse is taking or diverting drugs.( why this is a protected area I cant figure it) I think the OP put it very well put- we are expendable and disposable= what a ethical stanse on the value of human life from our so called PTB. If they place so little value on a a nurse's wellbeing, can any one imagine how little they value a patient's. I personally don't think they give a dam about either.

[2longasn]

Are there protocol investigations in progress. I mean calcium chloride for a child is a serious medication for a child. Are pharmacy guidelines changing because of this error. Good Nurses are good to everyone except themselves. I empathize with the family of the child is no longer hear. But why did the investigation end with Nurse's death? Is this an experience that the entire health care community could learn from?

[2longasn]

Still cannot wrap my head around this!

A seasoned nurse with nearly 30 years expereince makes a math error and is not only fired, brought up on BON charges but apparently blacklisted (or good as) as well.

Yes, one is *VERY* sorry for the loss of the child, but as the old saying goes "two wrongs don't make a right". AMEN As the writer to the Seattle Times pointed out, treating healthcare professionals whom make mistakes like this is counter productive. First of all it backs up the idea that you have to be nuts to report any error you make if you can get away with it.

This poor nurse begged and pleaded with the BON to be allowed to practice even with restrictions on her license, but it got her no where. So this is their idea of "protecting the public"?

One understands there is little to no room for error when dealing with meds for any acute or very acute patient, espeically a wee baby with many issues. But as the letter writer pointed out why was one nurse (no matter how good or seasoned) left to prepare and administer calcium chloride in that instance. The hospital changed it's proceedures after the incident so obviously what came before left room for mistakes.

Nurses out there you has my sympathies. If something like this can happen to a well seasoned nurse then the rest of you are one math error away from being out of a job. Talk about pressure![/quote]

Exactly............BUT FOR THE GRACE OF GOD GO I.......

To hospitals we are EXPENDABLE and easily DISPOSABLE!!!

A friend of mine (NOT a nurse) stated......"Truly terrible that she took her own life. Are nurses actively fighting to get the same leniency, so to speak, and protection from such initial events that doctors are guaranteed? " To which I replied....it will NEVER happen because nurses are EXPENDABLE AND DISPOSEABLE, we don't bring in revenue (like doctors bring in patients and insurance payments), we are a constant debit on the budget, we cost the hospitals money.......it's called a paycheck, and as a general rule we don't protect each other......very sad.

THIS REALLY BOTHERS ME........This has really broken my heart

I have experienced and witnessed the lynching that occurs when nurses are thrown under the proverbal bus for whatever reason, under the umbrella of good intentions and some misplaced self rightous perception of holier than thou attitude...............It makes me sick....

I pray she and her family find peace.......I pray the childs family to forgive...

[2longasn]

A million kudos to your post. There but for grace of God go us all.

[imenid37]

I feel very bad for her and the family of the infant. She did something any of us could do. This is just awful. You have to wonder if she was tired, distracted, had too many patients, etc. There was still a place in nursing for her. I hate that the very thing she loved most left her hanging. I hope she is with God and now feels peace, love, and forgiveness.

[2longasn]

deleted

[2longasn]

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.

Amillion kudos for your post. There but for the grace of God go all of us.

[2011NursingStudent]

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*

I just looked up the original article, and it looks like all of the nurses were really empathetic at that time and everyone recognized how easy it was to make an error. I guess one lesson that all of us here can take away as students, new nurses, seasoned nurses, is that if a mistake this serious ever does happen, the best thing to do is seek counseling because none of us is immune to mistakes, and none of us will be immune to the guilt that comes along with them.

[kcmylorn]

Something about that calcuim chloride infusion doesn't sound right to me. I have to wonder if - Did the hospital have all the safe guards in placeas they sid they did- I kinda think not. Doesn't pharmacy mix all drug infusions- I havent' mixed infusions or reconstituted meds in at least 20 years. What about the infusion pump- was it working properly- alarms. Don't 2 nurses have to check a pump rate together on the inital set up or a change in rate. Shame the BON closed it's investigation. I have to wonder if this nurse with her track record was really at fault at all? Seems mighty odd to me. JMHO

[Mukfay]

Do nurses honestly think a nurse who causes the death of a patient should get to keep their job?

If a nurse caused your caused the death of your loved one you want them to keep their job?

Would you want a nurse who had cause the death of a patient to care for your loved one?

As a nurse, would you want to share patient care with a nurse who had caused the death of a patient?

My answer to all 4 questions is no.

This is a tough one. However, you have to approach it in an evidenced-based way without emotion in order to benefit the patient pool in the best way. Who is more likely to make a mistake: The nurse who has made this mistake after 27 years, or another who has made a similar mistake, but was lucky enough to avoid a fatality? In a practical sense, they may both the same risk to future patients. A med error is a med error regardless of the outcome in the sense that future patients are at equal risk.

And yet, when you consider it, in all probability (and I suspect data would support this), the nurse who suffered this tragedy would probably be far more alert going forward than someone with a near miss.

So the answer to your last question in this case is an emphatic "Yes!" Trucking businesses are known for their desire to hire drivers with a single accident, and a clean follow-on record over a trucker with no accidents. Why? Because the trucker was shocked into hyper-vigilance.

We must also consider the imminent nursing shortage (only temporarily postponed), and the fact that nursing is an art that should be passed from generation to generation. Since you can't learn the art of it in nursing school, nurses like the one we are discussing are a priceless asset in the effort to educate a new (and very green) generation of nurses. Is it wise to waste this vast amount of experience and "sense" for nursing because of this terrible mistake?

I would say that dismissing her actually caused fatalities in a very real way because of the loss of her experience in the field. If you would gainsay my words, consider carefully before a possible knee-jerk reaction. There is a storm coming in nursing that will peak when we really begin losing the experienced nurses who are so absolutely vital to the education of the newbies, and it scares the hell out of me sometimes. Because to redevelop this vast body of knowledge will be next to impossible.

Regards,

Mukfay

[CompleteUnknown]

This story breaks my heart too Esme12. As many have said, there but for the grace of God go any of us. I can't stop thinking about it.

How do we as nurses deal with the possibility of making a devastating error? Is it something we should be thinking about more?

How do we, as mothers and fathers, daughters and sons, deal with the possibility of a fellow health professional making a devastating mistake that results in the death of our own child, parent or spouse?

How do we reassure our patients that we will keep them safe when the possibility of an error is ALWAYS there? How do we acknowledge to patients and families that errors are possible, without this frightening them, making them angry, or encouraging them to pick up the phone and contact a lawyer?

Are there degrees of error? Is a calculation error more or less serious than a judgement error or an error caused by inattention or poor staffing or lack of time? Is an error more or less serious because of the outcome or because of the reasons it was made in the first place? Is it more or less or less serious depending on whether the patient is nine, nineteen or ninety? More or less serious depending on the condition of the patient prior to the error being made?

Should there be some sort of 'no fault' compensation for the patient when serious errors are made?

Is there a point where the systems, processes, policies and procedures, and checks and balances put into place after a serious error actually stop from us being effective and perhaps even lead to other unforeseen problems?

We are humans, not perfect beings or machines, there will always be errors and some of them will have fatal outcomes. I've made my share of mistakes over the years, I'm just very very lucky that none of them resulted in permanent harm to the patient.