When Nurses Make Fatal Mistakes

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

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Career Columnist / Author

Nurse Beth, MSN

146 Articles; 3,468 Posts

Specializes in Tele, ICU, Staff Development.
I made an error where there was no harm to the pt, it was still a significant error to me. I felt I had no one to talk to, no where to turn. I ended up seeing a therapist and with in a year leaving bedside nursing all together as the ptsd and trauma from being the 2nd victim is such a real thing.

I'm so sorry. It's really under recognized - the second victim and trauma

Columnist

tnbutterfly - Mary, BSN

83 Articles; 5,923 Posts

Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Bumping this article back up in light of the current case involving a nurse being charged with reckless homicide as the result of a fatal medication error.

HomeBound

256 Posts

Specializes in ED, ICU, Prehospital.
On 2/16/2017 at 4:23 AM, Nurse Beth said:

Not at all. By behavioral choices, I meant the difference between a nurse who recklessly does not follow procedure and a nurse who makes a mistake despite doing so.

and here she hits the nail squarely on the head.

"The difference is---one nurse recklessly (and in case, WILLFULLY) does not follow procedure---and the other makes a mistake despite doing so (follow policy/procedure)

I'm not quite sure why people here can defend someone who...oh....forges signatures, charts something done when it wasn't (and it ends up in harm to the pt), purposefully bypasses safety checks in a pyxis, purposefully bypasses reading a label (while reading other parts of the label?!), purposefully defies policy on procedures...

Well...all I can say is that since some here have zero problem with me forging signatures---and that I can just get off with a slap on the wrist---can I borrow your blank checkbook? Because in reality---that's a felony.

Specializes in NICU/Neonatal transport.

I've seen myself that the emphasis sometimes on "just culture" means it can push people to absolve negligence. In the rush to not have anyone be blamed, sometimes there is some blame that needs to be doled out.

And I dislike the term "second victim". Tertiary victim I think is a better term.

While I do know some people are haunted by errors, others could be able to brush them off if consistently reassured that it wasn't their fault, they held no culpability etc. There are some people who are very capable of absolving themselves when given any encouragement.

I like to think I helped convince a nurse who committed an error that was a systems issue and there were far greater errors than hers, and that it wasn't that she didn't do anything wrong, but that everyone did stuff wrong, and it was unfortunate that it just all lined up that way. If it had been different people in the area working with her, if the call sheet had been correct, if a different resident had been on, if she hadn't been so new, if other things hadn't gone wrong, then the patient still probably would have died, unfortunately, but the errors wouldn't have reached the patient. It wasn't that she didn't make any mistakes - she did. We went over how to not make those again, and some of hers came from inexperience, but I also went over how the system should have caught her mistakes ideally, and how each step in the chain broke and how it should have gone.

Now, I don't know what kind of counseling the resident involved received, but she had arguably more true negligence, and she definitely didn't quit, and I was frustrated because when I would try and bring up some of the negligence issues, it reverted back to "we don't want to throw around blame" etc. I still see some of the same issues with her.

There needs to be a middle ground between "no consequences" and "throw everyone under the bus". Or, as I have also seen in other hospitals "be real quiet about it and move the nurse to minimize liability".

wondern, ASN

694 Posts

December 26th, I was going to just post the date and just say enough said but nooooo I had to go on....I'd be willing to bet she was really tired and working short staffed. I wonder if she had kids or family at home and had been up all night and day cooking and shopping for Christmas on top of then going in to work short-staffed and really tired???

I'm glad the family of the patient has been supportive of the nurse somewhat it sounds like. That speaks volumes to me. They probably saw how short-staffed it was everywhere. I don't know. It's an educated guess.

Sometimes managers are hired with big degrees (masters' degree Bridge programs) that haven't really worked much as nurses in real life but then are hired to manage all the worker bees. Are you kidding me???! They sometimes do all kinds of stupid/ignorant stuff, sometimes even undermining good nurses to buddy up with buddies who are flat out slackers. Why did that manager send her? A newer nurse? Maybe the manager wasn't even an experienced nurse herself or a nurse at all! Maybe the manager had no clue. I know, maybe, maybe, maybe...just saying I have a hard time placing all the cause on just the one nurse. I bet it was a charge nurse that sent her and the manager may have been on holiday. Just a guess. The manager probably wouldn't even really know what's going on on the floor that day. If not off for the holidays, she's probably in manager's meetings on how to cut costs and save money.

I wonder if the hospital paid the family for any damages? Or sent them a bill? (Shame on me for wondering that but I do.) Or anything, maybe a card? Free healthcare for life? To me, it seems the hospital would claim the ultimate responsibility. To me, they allowed it to happen by allowing that non critical nurse in a critical care area basically because they didn't have enough staff. I see it that way.

Practically everyone wants off the week between Christmas and New Years. At the same time a lot of patients are jamming in to get some elective procedures done before thier deductibles run out. Hospitals need to provide more staff for that. It seems as if they would know that and prepare with extra staff. These fine institutes frequently pay for studies on the very issue of patient acuity and staffing that also puts extra burden of the analytics work on the nurse, then they go on to not provide the actual help in staffing for that very nurse the study was supposedly done for. Shame. So really to me the study is to cut costs and staffing that is much needed, not increase staffing or retain experienced nurses. Not to mention holidays off are also often determined by seniority so lots of inexperienced folks are left to work without the expertise of the experienced folks on holidays. Just a formula for the perfect storm. The sadness and irony to me are profound. Too many steps were involved. Just no! The nurse was the end provider but to me not solely responsible, just no!

Heck, even Sully got on national tv and said he felt that Boeing and the FDA had too friendly of a relationship that kept that jet flying an extra week or two maybe, that took all those lives, so 'no', I don't find the 'friends playing golf' theory way off base. Does anybody know if the hospital claimed any of the accountability??? Give me a break! No pun intended!

wondern, ASN

694 Posts

On 2/21/2019 at 3:04 PM, LilPeanut said:

"Now, I don't know what kind of counseling the resident involved received, but she had arguably more true negligence, and she definitely didn't quit, and I was frustrated because when I would try and bring up some of the negligence issues, it reverted back to "we don't want to throw around blame" etc. I still see some of the same issues with her. "

Hmmm, reealllyyy, that is frightening! ?‼️

Wuzzie

5,116 Posts

1 hour ago, wondern said:

I'd be willing to bet she was really tired and working short staffed.

Except she admits she wasn’t and they weren’t. ?

And she was a critical care nurse working as a resource nurse on her own unit.

wondern, ASN

694 Posts

Hey Wuzzie. I just actually read the actual report of what she said. I wonder if she was encouraged to deny being tired by her lawyers.

So she was from the NICU sent to the adult PET scan area then on to the ER. Good-night! That sure sounds like a shortage to me.

edit-Oh the N is for neuro not neonatal, right?! Now I get it.

I thought she was from the floor. I've never even heard of a 'help all' nurse. Registry, float, yes, help all, no.

Specializes in NICU/Neonatal transport.
9 hours ago, wondern said:

Hey Wuzzie. I just actually read the actual report of what she said. I wonder if she was encouraged to deny being tired by her lawyers.

So she was from the NICU sent to the adult PET scan area then on to the ER. Good-night! That sure sounds like a shortage to me.

edit-Oh the N is for neuro not neonatal, right?! Now I get it.

I thought she was from the floor. I've never even heard of a 'help all' nurse. Registry, float, yes, help all, no.

They call it different names on different units. We have "zone leaders", "break relief", "triage" and "resource" nurses. All of those nurses are tasked with helping out others. At another hospital I worked at, we had 2nd and 3rd charge who helped out. It's just a matter of naming.