Nurse's suicide after fatal baby overdose mistake highlights twin tragedies of medical errors

[RamboLiberal]

For registered nurse Kimberly Hiatt, the horror began last Sept. 14, the moment she realized she’d overdosed a fragile baby with 10 times too much medication.

Stunned, she told nearby staff at the Cardiac Intensive Care Unit at Seattle Children’s Hospital what had happened. “It was in the line of, ‘Oh my God, I have given too much calcium,’” recalled a fellow nurse, Michelle Asplin, in a statement to state investigators.

In Hiatt’s 24-year career, all of it at Seattle Children’s, dispensing 1.4 grams of calcium chloride — instead of the correct dose of 140 milligrams — was the only serious medical mistake she’d ever made, public investigation records show.

-----

That mistake turned out to be the beginning of an unraveled life, contributing not only to the death of the child, 8-month-old Kaia Zautner, but also to Hiatt’s firing, a state nursing commission investigation — and Hiatt's suicide on April 3 at age 50.

http://www.msnbc.msn.com/id/43529641/ns/health-health_care/

What a tragic story. I think some of this should be on hospitals - need a way of making this kind of mistake impossible to make. Humans screw up and with shortage of staff and incredibly long hours it happens.

[midnight]

1. K&R...

[iwishiwas]

2. yes, mistakes do happen and she admitted it immediately. This

is so tragic for both families.

[Mojorabbit]

3. As a retired nurse I can say

we all are human and mistakes will happen no matter how careful you try to be. What a tragic situation.

[Codeine]

4. We need to accept that the same people who have the power to save hundreds of lives

may accidentally end one in the course of their career. If they are otherwise competent and haven't acted maliciously then we need to have a different way of dealing with them than destroying their lives.

[ZombieHorde]

23. The vast majority of nurses don't kill anyone. nt

[Brickbat]

26. Agreed.

[tblue]

5. I bet she saved many children's lives over all those years.

She must have loved children. Oh how sad. Can you imagine the guilt she suffered? And she had a stellar career too

That's one reason I would not want that job. I'm sure I wouldn't survive this either.

[tabasco]

6. Nursing is one of the most difficult jobs in the world.

Mistakes should be expected. This was a serious mistake but the nurse should not have been fired. There should have been remedial training and that is it. This is a situation when the mistake is punishment enough. This was a conscientious woman, as I read it.

[ZombieHorde]

9. If a nurse accidentally killed my 13-month-old, I would want her fired and I would press charges.

I have given out a lot of medicine in health care facilities. You're supposed to check three times; before you touch the medicine, as you're preparing the medicine, and before you give the medicine.

[jwirr]

13. Those procedures are good but it would be even better if another

nurse were to do the final check.

[ZombieHorde]

14. I completely agree. That is a fantastic idea that protects both the patient and the nurse. nt

[tabasco]

21. How merciful and compassionate of you.

Hard to believe, but you could make a mistake someday.

[ZombieHorde]

22. I have made a lot of mistakes, but none of them have involved killing people.

People who kill my family members should be prepared to defend themselves in a court of law.

[CTyankee]

20. I don't know that much about the nursing profession, but couldn't there be some of

back up system of re-checking where such delicate situations involving a fragile infant occur? Or a check-list of some kind? No one person is omniscient or perfect. there will always be simple errors. Having a system that can check what you are going to do could really help avoid such tragedies.

[Seedersandleechers]

35. In the hospital I worked in there were medications

that required another nurse to check the dosage. It worked great as med errors were drastically reduced.

[arikara]

7. That is so sad, on both counts

my daughter is in nursing and the pace and extreme stress of it now guarantees that there will be mistakes made. She says they have made so many staffing cuts now that pretty much all the nurses have time for is to administer meds.

[peace frog]

8. I was devastated when I read about the suicide

of my anethsesiologist who administered the epidural for the birth of my second child. He was on the emergency room staff when a baby was rushed in for emergency surgery. The doctor carefully and correctly administered the anesthesia but the child had an allergic reaction to it and died on the operating table. My doctor was so devastated he committed suicide even after a medical review cleared him of all wrongdoing and actually praised him for doing all he could to save the baby. He just couldn't live with the baby's death on his conscience, poor man.

[Codeine]

10. That's brutal on so many levels.

:hug:

[peace frog]

16. Yes, it was tragic

He was one of those doctors beloved by hospital staff and patients alike. I still get teary when I think of it.
Thanks for the hug.

[patrice]

11. It is an under-appreciated fact about nurses and nursing that . . .

My three nieces tell us: Pretty much on an average, many nurses aren't necessarily interested in organizing to get higher pay, or for more benefits, and there are such serious staffing shortages everywhere that they are not particularly concerned about job security either.

What they want are work environments in which they CAN, in which they are allowed to, do their professional best, as opposed to work environments in which there is pressure to go along to get along. Nurses like to be able to sleep at night after each day's challenges, so they want work environments that do not handicap them until someone/something breaks and someone gets hurt.

[uppityperson]

25. + a brazillion. That is the reason so many of us get out of the profession.

[medeak]

12. saw docs make horrible mistakes

working in ER in another life...and they never had remorse. On drugs working graveyard. So many stories of abuse to pts and employees. Nurses are so under rated covering for these guys imo.

[mzmolly]

15. It seems to me that medication should be dispensed under a system of dual control.

Two people should approve doses of medication prior to their administration. In fact, having a separate individual measure and dispense medication to nurses would probably be best. Someone with training and access to a computer system that double checks medication dosages by patient's known body weight etc. An internal pharmacy of sorts?

It wouldn't hurt to consider other procedures being double checked as well. Banks use this system when it comes to protecting money. People are more important.

Such a sad story.

This is astounding.

"No question, the patients are the top concern in a nation where 1 in 7 Medicare patients experience serious harm because of medical errors and hospital infections each year, and 180,000 patients die, according to a November 2010 study by the Department of Health and Human Services’ Office of Inspector General."

Something has to be done to protect nurses and physicians along with patients.

[pitohui]

19. casino cages sometimes "double" as little as $800 & virtually all of them over $1500

it shows you that human life is worthless, of less value to "double check" than a few hundred dollars worth of chips

everybody makes mistakes, that's why you call "double" when it's important to have that second set of eyes

true, money is hard to come by, while we live in a world of 7 billion and a baby is of very little value in the scheme of things, but we're not supposed to make it so OBVIOUS that a baby is of little value and it's not worth calling a double check when giving meds to a baby

there's this big pretense that human life is important, it is the LEAST important thing in our society

money is all, and saving the cost of the second nurse is worth it to the hospital, and if a baby has to die to keep down their bottom line, no worries, they'll blame the nurse and ruin her life so it costs THEIR bottom line nothing at all, there are lots of nurses and more of them coming every day from the philipines

what a sick world we live in

[McCamy Taylor]

31. MOst meds are. However, in ER, ICU and emergencies some meds are drawn up by the nurse

or doctor without a pharmacist there to check the dose. If the doctor orders a routine med on the floor, the pharmacy will make sure that the does is the right one.

[Ilsa]

34. Alot of IV meds are pre-dosed in small vials and kept in stock on the floor.

At the ICU level, there is an expected higher standard of care, but this isn't necessarily codified or in policy in many organizations. It is simply that the more experienced nurses usually are requested to work ICU or ER where experience is needed for rapid assessment and action.

I feel for the family of the baby. But I also wonder how they feel about the nurse's death.

[CaliforniaPeggy]

17. How horrible for all involved...

I am retired from nursing too, and I made my share of mistakes. I always said better support was the thing I most craved: better staffing, especially.

But better staffing costs money.

:shrug:

[jmowreader]

18. There is a way to cut down on medication errors...

and it's done in the socialized medicine system our government runs called the Veterans Health Service.

When you get drugs as an inpatient at the VA, first the doctor prescribes them to you. A prescription is not complete until he enters it into the Big VA Computer in the Sky. (This goes for everything except basic fluids in the emergency room--as long as it gets in your record, the doctor can just grab a bag of solution, hand it to the nurse and order it be put into the patient.)

Once the prescription reaches the pharmacy, a pharmacy tech and a pharmacist prepare your dose. The computer spits out a barcode label for the drug--pills or injectables, same thing. Injectables have a barcode printed on the bag at the factory, and they scan that too.

When the drug reaches the floor, first the nurse will ask you your last name, date of birth and last-four of your social security number and feed it into the computer. The nurse will then scan your barcoded armband. The nurse will then scan the barcode on the drug. Only if the information on the patient, the drug and the computer match will they give you the medication. It's probably possible to make a medication error at the VA, but you'd have to work at it.

Knowing what I know about the VA versus the civilian medical system, once the wars end I would recommend every young person do a hitch so he or she can use the VA...since you know there's no fucking way in hell the Republican Party will ever let the government set up a similar system for lifelong civilians. It really is a good system.

[Bunny]

27. I saw that firsthand when a friend was in inpatient at the VA hospital.

Anytime the nurse rolled up with the pill cart (or 'Pain Wagon', as it was also called), it was all computerized and triple checked before anything was administered. I assumed this attention to detail was because some of the medications were controlled substances. It's good to know that this procedure covers all meds. You would have to go out of your way to make a med error, from what I observed.

[cbdo2007]

32. You aren't addressing the issue....she accidentally gave TOO MUCH

medicine to the baby. It wasn't the wrong medication.

[rainbow4321]

33. And we have "high risk" category meds at the VA

Things like insulin, any blood thinner (oral or IV), any IV electrolyte (potassium, magnesium, etc..), and a few others. We scan the patient's armband, the drug barcode, and then have to go verify that high risk drug with another nurse--we then scan that other nurse's "verified by" badge so we can show the system that we double checked it.

Now having said that, I have seen some nurses kind of bypass that verify part by swapping badges with another nurse so they can just scan the other nurses "verify" barcode without going to have to hunt down another nurse while they are busy passing meds to other patients. Or they will approach you without the medication and want to "scan" you.
Personally, I do it the right way. Draw up the med (insulin, heparin) and show it to the other nurse and ask if I can "scan" them. I've had nurses not even give the syringe a glance as they hold up their verify barcode for me to scan. Hell, the charge nurse I scanned last night didn't even look up from his computer screen at me, he just flipped him badge up my way for me to scan.
I don't think that they realize the seriousness of the "verify" part. Their NAME and title are attached to that dose given. Good luck explaining how you verified the wrong dose if something goes wrong.

ALL meds have to be scanned into the system, whether they are high risk or not. And administration keeps track of "not scanned" meds, plus if you are giving the med but not scanning it, the medicatiopn administration software makes you go thru hell if you "tell" the hand held computer you are not scanning it for some reason. Not worth it. I've had to schlep on down to pharmacy myself to get a better med bar code if the initial one won't scan.


But, yes, overall, the VA med system is really good when it comes to medication administration. I love the handhelds that we use to scan the patients and the meds (well, when they are actually working, our's are on their last leg!). It sure beats the private sector where some have these huge carts you have to push around just to scan someone. Or they put a computer in the room attached to the wall. Which sounds great but if that computer breaks down, you are screwed since they have no handhelds as a back up.

The other thing at the VA is..doctors CANNOT give verbal orders. They HAVE to enter it into the computer. So there is less chance of the order being misheard, misunderstood, or the doctor saying "I didn't say that order, the nurse heard wrong". I've had some of the newbie docs try to give a verbal and have been able to tell them "nope, you gotta get to a computer".

I have worked in a neonatal setting, also, at private hospitals. Most drugs are verified by a second nurse. Especially electrolytes (like calcium) Did the hospital in the OP not have that system set up?

[Shagbark Hickory]

24. I had no idea calcium was deadly.

[Name removed]

28. Deleted message

Message removed by moderator. Click here to review the message board rules.

[WatsonT]

29. That's horrible

It's an understandable mistake (misreading a decimal point once every 24 years seems reasonable to me).

Poor woman.

[McCamy Taylor]

30. The hospital's actions are designed to keep employees from admitting when errors have been made

in order to save the hospital from the threat of the lawsuit. Errors happen all the time.It is just that very few admit to their errors.

This case will make sure that the employees stay silent.