When Nurses Make Fatal Mistakes

All practitioners make mistakes. To err is human. But how do we treat nurses who make deadly mistakes?

Jessica's Story

Jessica was a young, conscientious nurse in her first year of nursing.

Jessica was having a typically busy day on Tele. One of her patients, a middle-aged male in Room 4152, was on a Pronestyl drip for arrhythmias. Pronestyl is an antiarrhythmic drug that has pro-arrhythmic properties and a therapeutic range must be maintained. When the cardiologist rounded early that morning, he wrote an order that the Pronestyl drip be discontinued.

Around 1500 that same day, a code was called in Room 4152. The patient was in ventricular tachycardia and despite all resuscitative efforts went into ventricular fibrillation. The patient died.

Only after the patient was pronounced did someone look up to see the Pronestyl drip running.

I observed all of this from the distance of a staff nurse who was not privy to whatever discipline took place. I can still recall the sick feeling I had when I heard about the error. Almost as if I had endured a close call myself.

In the following weeks, I remember realizing that Jessica was gone. Did she quit or was she fired? No one spoke about it. Where did she go? Did she recover from her mistake? I still think of her and wonder where she is and what's she's doing. My belief is she quit nursing at that time.

I do not believe the organization terminated her, because it was against the culture at the time. But they also did not support her or the staff through the experience.

Wrong Blood

At that same organization, an RN in ICU who was managing 3 blood transfusions at one time hung the wrong blood and the patient (a terminal patient) died as a result. She was not fired and went on to practice for many more years.

She appeared to have resilience and bounced back. But not all second victims of fatal errors are able to recover.

Medication Error

There's the tragic story of Kim Hiatt, an RN who worked in Seattle Children's Hospital ICU. Kim had worked there 24 years and by all accounts was a dedicated, compassionate nurse with a heart for families.

On September 14, 2010, Kim received a verbal order to administer 140 milligrams of calcium chloride IV to her patient, a nine-month-old. She drew up 14 mLs because 14 mLs X 10 milligrams per mL = 140 milligrams. She labeled the syringe with the dosage.

Tragically, she was wrong. There were 100 milligrams of calcium chloride per mL. Not 10. Kim should have given 1.4 mLs. Not 14 mLs.

The mistake was not uncovered until hours later when the nine-month-old's heart rate was faster than expected and a blood level of calcium chloride revealed abnormally high levels.

Kim was immediately ordered to leave, escorted out of the facility, and subsequently fired.

The nine-month old baby died 5 days later. It is not clear how much the error contributed to the death as the baby had severe heart problems and was described as frail.

Meanwhile, the Washington State Department of Health opened an investigation to decide if Kim could keep her nursing license. She was given 4 years probation where she was to be supervised when giving meds.

On April 3, 2011, 50-year-old Kim, a previously highly regarded NICU nurse and now a pariah, and no longer able to cope, hanged herself in her basement.

In Kim's case, the facility did not have sufficient safeguards in place to help prevent the error. She did not violate policy. The doctor gave a verbal order, which was permitted, and Kim performed an independent calculation, which was permitted at the time.

Some claim an atmosphere of fear followed Kim's mistake and subsequent firing- nurses at Seattle Children's Hospital were fearful to report errors believing they could lose their jobs.

Also, read Nurse Gives Lethal Dose of Vecuronium Instead of Versed

a tragic incident that happened at Vanderbilt Hospital.

Second Victims - The Nurse

To err is human, as the Institute of Medicine tells us. It also tells us that a series of adverse events can rarely be attributed to one person.

In a just culture, mistakes are differentiated from recklessness, and systems are examined for causative factors.

Second victims of trauma are often overlooked as needing support and compassion. Patient safety is dependent upon not only preventing mistakes but our actions following mistakes.