Tragic end for dedicated nurse

tyvin, BSN, RN · Jun 27, 2011

Very sad ...

Music in My Heart · Jun 27, 2011

i think this is reflective of the punitive attitude that we have in our culture. the general response in most workplaces to serious mistakes that have serious repercussions is to (figuratively) hang the person who did it as though that somehow solves the problem.

on the other hand, if the mistake - though very serious and potentially devastating - didn't actually cause harm, the perpetrator is often given another chance.

all that said, i find nurse hiat's comments in her report disturbing:

"i messed up," she wrote.
"i was talking to someone while drawing it up." big mistake #1... and not a personal mistake so much as a cultural deficiency in this unit... many of us do it but i think we all know that we should not disturb people drawing up meds... and that we ourselves should ignore interruptions when we are drawing up meds. this lady bears some responsibility but the "blame" really falls upon the system and the culture itself.
"(i) miscalculated in my head the correct mls according to the mg/ml. now for this, she is responsible. no matter how experienced we are with calculations, we shouldn't be doing them in our heads. i am very, very, very good at math and yet i still force myself to write out my calcs (at least with critical meds) with all the units shown. it's the only way to be certain that simple order-of-magnitude errors like hers don't occur... and it's the only way for someone else to verify same.
first med error in 25 yrs. of working here. i find this a bit disturbing simply because i doubt that it's true. i'll accept that it's the first serious error but i seriously question if this is the first time that this nurse hasn't completely and fully met each of the 5 (or 6 or 7 or 10, depending on who you ask) rights. this comment demonstrates overconfidence to me.
i am simply sick about it. of course she was. i have so much empathy for that feeling in the pit of her stomach when she realized what she'd done. recently i spent 3 minutes thinking that i'd given a heparin drip - for hours - at twice the ordered dose. i hadn't (thankfully) but those 3 minutes were horrifying.
will be more careful in the future. this disturbs me as well because it doesn't address the root cause(s)... and it's not a matter of being more careful... and even if we *intend* to be more careful, that's a tall order to fulfill over the long term.

i hate that she was made the sacrificial lamb and so saddened that she was made so hopeless by the destruction of her career and the error that she made that she couldn't choose to go on with her life - and that her kids are now partially orphaned.

maxcat · Jun 27, 2011

This is the kind of thing that absolutely terrifies me to the core...as someone who has chosen nursing as a second career, and is starting clinicals in the fall!!

MusicEMT · Jun 27, 2011

That is sad.. my heart goes out to both families..

from the looks of it. it appeared to be a simple Metric system conversion error

one big reason we should abolish the US Mesurement system and start teaching the Metric system to kids to the point its second nature...

i wonder how much of it was fatigue? unfortunately healthcare workers are one of the most overworked professions out there (IMO)... thus long shifts and lack of down time can cause fatigue and errors quite quickly.

a tragic accident non the less.. hopefully i will never have to face such a situation in my lifetime

Music in My Heart · Jun 27, 2011

from the looks of it. it appeared to be a simple Metric system conversion error
one big reason we should abolish the US Mesurement system and start teaching the Metric system to kids to the point its second nature...

After 25 years as a nurse, I think this lady was very familiar with SI units. In fact, the cause of this error was directly related to the action *being* second nature after having done it innumerable times.

The root cause of this error was distraction, pure and simple.

punkydoodlesRN, BSN, RN · Jun 27, 2011

Read about this before and found something new in this article that changes the picture. Any way you look at it, could be any one of us facing the same consequences. Sad for everyone.

I think this has been posted on here before, remember reading about it earlier. What was it new that you read?

nursehopeful2011 · Jun 28, 2011

I don't know if anyone else has posted this story. But it is just so sad, and highlights how much of an emotional toll this profession can take on good nurses.
http://www.msnbc.msn.com/id/43529641/ns/health-health_care/

This is terrible. I feel reallybad for the baby and the baby's family as well.

nurseabby28 · Jun 28, 2011

This is just an example of just how stressful nursing can be. I pray none of us ever have to live with the guilt of causing harm to a patient. How sad :crying2:

demylenated, BSN, RN · Jun 28, 2011

After 25 years as a nurse, I think this lady was very familiar with SI units. In fact, the cause of this error was directly related to the action *being* second nature after having done it innumerable times.
The root cause of this error was distraction, pure and simple.

I agree with you. We all know the conversions. They ARE second nature. The moment in PEDIATRICS AND CRITICAL CARE that you start doing THOSE CONVERSIONS "in your head" is the moment you have gotten laissez faire with your job, imho. It IS a tragedy... but one caused, probably, due to distraction... unfortunate as that is.

I think this is a LEARNING opportunity, unfortunately the lesson right now is STHU or lose your job. With that attitude, we will never feel completely confident in learning and keeping safe. Where's the line. It is a fine one, sure... but we are human... there will ALWAYS be mistakes... the less they are reported, the less we learn as to how to improve quality care. It is a vicious cycle, and until someone stands up and says losses ARE inevitable BUT they can lead to moving a profession forward, no matter HOW much it hurts (as long as it is not complete negligence) we will never go further, because no one wants to admit a mistake due to the repercussions.

panamishe · Jun 28, 2011

My heart goes out to her family...

Butterfliesnroses · Jun 28, 2011

What a sad situation! I remember as an aide, I reported a nurse, who was fired, because she was mumbling to herself mg=mL...I was taking nursing math at the time and I said NO it doesn't! She was pouring out liquid MS into a med cup and was measuring it as if mg=ml. It was 20 mg/ml. I reported this bc I was SCARED for the residents she cared for. Had I not been standing there she would have given the resident 20 times the amount she was supposed to. FWIW I did feel bad about reporting her to our boss and stuff, but this nurse was making HUGE mistakes like this on a daily basis and I do believe she had dementia, she had many of the classic s/sx.

DoGoodThenGo · Jun 28, 2011

The story in the OP link is an update to an event covered here in the group at least twice; once at the time of the med error (resulting in the infant's death), then later after Nurse Hiatt's death by her own hand. This recent piece serves to flesh out some of the background details surrounding the original error and subsequent actions that lead to the nurse's suicide. It also is written from a point of view advocating better treatment for nurses and other medical professionals who commit dosage (or other) errors.

For instance we now know that Nurse Haitt was not unknown to the infant's family and had treated the patient several times in hospital since her birth. We also know what the nurse disclosed in self-reporting the error, and how the hospital reacted.

Quite frankly one cannot help but agree with statements by the hospital that there is *more* that went on than just the dosage error. I mean a nearly 30 year veteran nurse was escorted off the hospital grounds link a criminal just because of an error? What is up with that?

Had hoped Nurse Haitt's sexual preferences would not be paraded about like dirty laundry, but we now know there was a same sex harrasement complaint against her from another nurse.

"Her attention to detail and her precision is not what I would expect it to be at this point in her career." That statement from the hospital worries if not scares me. Just what else was going on or had happened to warrant such a remark? Would be interesting to see Miss. Haitt's annual reports (not that we ever will, nor should we), to see what if anything was found lacking in her performance. I mean the woman was there for nearly 30 years, if she wasn't on top of her game why not fire her and be done with it? Or, adopt the common "transfer, float" routine until Nurse Hiatt got the message and moved on of her own accord. If her attention to detail was not up to standards why was she allowed to remain on the unit?

The article reveals the actions of the WA BON, and that while her license was not suspended nor revoked, NH felt all the same her nursing career was over. Sadly she was probably correct at least as far as WA state was concerned. The chances of another hospital touching her after her name had been dragged through the media mud by the reporting of her patient's death were likely slim to nil.

Being as all this and the rest maybe, it does seem NH was careless in not devoting her full attention to the matter at hand (preparing meds), and giving 1.4 grams of calcium chloride,instead of the correct dose of 140 milligrams.

From one's first med/dose calc class it is drummed into your head not to simply become an automat and just do the sums to arrive at a dosage, but then to "look" at the answer and see if it makes sense in relation to your patient. Granted much of this will come with experience, but one has to wonder if it was the chatting with someone else, a distraction or was she being rushed that made an experienced nurse over look this critical point.

Children's seems to hint that something much larger than the one error brought all this on. And in a roundabout way not only sticking to the common "she had it coming" line, but seem quite pleased with themselves and the way they handled the situation.

The whole thing is a very nasty and sad business. IMHO someone needs to go into Children's and look in every crack and corner to find out just that is going on between the hospital and it's nursing service. Something about this just doesn't add up and quite frankly has a whiff about it.