Nurse suicide follows infant tragedy - page 4

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

  1. by   2longasn
    Quote from DoGoodThenGo
    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 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'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...
  2. by   2longasn
    A million kudos to your post. There but for grace of God go us all.
  3. by   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.
  4. by   2longasn
    Last edit by 2longasn on Apr 24, '11 : Reason: redundant
  5. by   2longasn
    Quote from babyRN.

    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.
  6. by   2011NursingStudent
    Quote from 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*
    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.
  7. by   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
  8. by   Mukfay
    Quote from kids
    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.

  9. by   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.
  10. by   wooh
    Quote from kids
    Would you want a nurse who had cause the death of a patient to care for your loved one?
    I'd much rather be cared for by a nurse that knows their own fallibility than with someone who thinks only a "bad" nurse could make a lethal error.
  11. by   gentlegiver
    When I read this thread, my first thought was how sad for the child,the Nurse, and both families. My second thought is that all Nurses are guilty until proven innocent. And sadly this is very true, the employer is all to happy to throw us under the bus to save thier profit line, the BON will judge you on "evidence" provided by the employer (and examined by thier lawyers to give the employer the best chance of getting out of a situation without cost), and you are left to try to present your side of the situation without seeing the evidence against you while the BON insists you sign whatever paperwork they want that usually admitts your guilt (whether you're guilty or not)so it looks like thier looking out for the public.

    But, what everyone fails to see is the severe depression that a Nurse of 27 years, dedicated to perserving and saving the lives of thier patients, goes thru knowing that she (this one time) failed to cause no harm. The hospital (in an effort to minimize the financial cost to themselves) ignored her mental and emotional distress, the BON I''m sure did not even bother to look at her or talk to her about her situation other than to impress her guilt on her. Where was her family, her friends? Did they not see the ramifications of losing everything she worked for all her life(especially those that are Nurses)? Did her lawyers even think that depression can and is a direct result of her situation? She at that point was incapable of seeing her mental statis, those in depression usually don't realize how bad it is until it's to late. For this poor Nurse the entire system failed to protect her from her biggest danger, her own depression. Everyone of us is in the same boat, and it doesn't take much to sink it.

    In this case we all lose, we lose the potential of a child, the knowledge of a veteran Nurse, the chance to effect change that would do good.
  12. by   cdsga
    Support??? There is no support for nurses who make mistakes and cost a life. This profession is NO JOKE. When you make a mistake, your own peers will desert you. It's horrible. Some feel bad for you, pity you, sympathize with you, but they have no idea what it takes to get your profession back. When you have worked this long (over 20 years) in a profession that you are called to, it is part of your identity/persona. If you are a nurse, your job doesn't stop when you leave the workplace. Family, friends, etc call on you for advice, help on your off hours. It's a 24-7 deal. This is a clarion call to all nurses to support and comfort those who are faced with this type of problem. Career change counseling, networking are all needed to get the injured and traumatized nurse back on their feet. Financial assistance, and psychological counseling are necessary. No one intends for bad things to happen-of course there are a few wacko's- but to treat someone like this was intentional actions is so cold and heartless. No wonder she lost hope. It's a hard blow for us all. We all are one mistake away from this very situation. BELIEVE IT!!!
  13. by   DoGoodThenGo
    Quote from kids
    I am sorry for the losses suffered by families on both sides of this tragedy but I just can't get on board with the idea that the hospital threw the nurse under the bus.

    For whatever reason she made a mistake that resulted in a death.
    Accidents and mistakes happen but they still have consequences and you're still responsible for the outcome.
    If you kill a patient you don't get to keep your job. Harsh? Yes but it's a natural consequence whether you've been on the job for 27 years or 27 days.

    Causing the death of a patient is a career breaker even if the BoN eventually clears you to practice. To the hospital's insurance company and to the insurance company of any future employers it doesn't matter if it was a one time mistake in a long unblemished career the nurse is now uninsurable.

    I also don't feel it's an admission of anything that the hospital changed it's policy after the error. It's basic risk management, policies are written or re-written any time there is a need for it, good or bad.

    I can't begin to imagine the grief and guilt this nurse felt but choosing to deal with it by ending her own life is exactly that, her choice. The hospital, the BoN and the people who didn't hire her are not to blame for her suicide, she chose to end her life, she chose to inflict additional grief on her family.

    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.
    I must say find that sort of attitude rather harsh, especially in this situation where we no nearly nothing as to what caused a nearly 30 year experienced nurse to make a "math error".

    As for keeping nurses on who cause the death of a patient, what about physicans from post graduates to august doctors who cause death. By and large then we hear a different story don't we? What is sauce for the gander is sauce for the goose,that's what I say.

    We all know med dose errors come in several forms, and yes some when they result in death probably do deserve to have a nurse in question discharged and or reported to the state for action. Being as all that may, even when an error does result in a tragic outcome, it does not automatically follow that the nurse is not safe to practice.

    Because nursing staff often administers meds, they are usually on the hook for whatever happens afterwards, even bad decisions by the hospital or whom-ever designed the system and or pharmacy.

    One assumes still covered in every student nurse's med dose calc class, the reconstitution of medications by nursing staff in hospital has changed over the past twenty or so years. As a result by and large much of it is now done via the pharmacy, and not on the floors/units by individual nurses.

    Reconstitution of powdered meds throws an extra wrinkle into the dosage calcuation as one has to dilute properly to obtain the correct amount of medication per unit of measure. If the concentration of solution is incorrect (to strong or too weak) amount given will not equal doctor's orders. A nurse normally working with adults but some how finds herself in peds, may slip and prepare a solution based upon the ratios she is used to working with.


    The above study illustrates just what can go wrong when nurses, even experienced ones deal with reconstituted meds.

    It would be interesting to have known several bits of information regarding this whole tragic incident. What were the doctor's orders? What was the hospital's standards, practice and proceedures for preparing and drawing up sodium chloride for injection and or infusion? What was the infant's condition and diagnosis? Would even the proper dosage as written have had the potential for a very bad outcome? What was going on with the nurse whilst she was making-up the meds? In short everything from the doctor's order to administration should be looked at. We know via published reports Children's came to some agreement with the nurse (but didn't offer to have her back), along with changes to their proccedures after the fact.