A Medication Error Leads to Suicide

A nurse commits suicide:

Kimberly Hiatt, 50, a longtime critical-care nurse at [Seattle Children’s Hospital], took her own life April 3. As a result, the state’s Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant’s death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt’s mother.

“She absolutely adored her job” at Children’s, where she had worked for about 27 years, said Crum. “It broke her heart when she was dismissed … She cried for two solid weeks. Not just that she lost her job, but that she lost a child.”

Is it just for a nurse to be fired for a medication error, even if lethal? Most hospitals do have procedures in place to deal with such errors, aimed at discovering the root causes of mistakes in order to improve patient safety. A key part of this process is to encourage nurses to report medication errors and even near-misses without threat of retaliation or disciplinary measures, but instead to offer education to strengthen skills and critical thinking. The hope is that in doing so, flaws in the process of drug administration can be easily identified and corrected.

Unfortunately, such an arrangement requires a certain degree of trust between management and the front line. When I worked in the U.S., management decided to implement a “No discipline, no retaliation” policy for medication errors. When the ED manager was asked if there actually would be no discipline taken for medication errors, she laughed and told us it would be “situational.” You can guess how successful the new policy was. Once trust is lost between front line nurses and management, it’s difficult to restore.

Firing a nurse distracts from actually promoting safety in a meaningful way, and diverts attention, as Kevin Pho points out, from where responsibility ultimately rests for ensuring safe medication practices: the senior management. Hospitals will fire nurses in the mistaken belief that removing a nurse who has committed a lethal error — an easy target, at that, if truth be told — will somehow reduce risk and liability and demonstrate commitment to patient safety. In fact, the precise opposite is true. By disciplining nurses who commit errors, and by not engaging in remediation with these nurses,  a climate is created where errors, if they occur, are likely to go unreported and unresolved — and substantially increasing risk.

It it enormously tragic a 8 month-old child died as a result of a medication error. And to be clear, none of this evades the ultimate responsibility of the RN to administer medications correctly. It’s important to note the state nursing board imposed substantial sanctions on this nurse, just prior to her suicide, including a requirement to be supervised while administering medications for four years.

Yet it’s also tragedy multiplied that the Seattle Children’s Hospital saw fit essentially first to scapegoat her, evading its own responsibility, and then to drive a 27-year veteran from the profession, leading to the point where she saw no other option but to kill herself. It’s interesting, in the context of the discussion around bullying this week in the nursosphere, that this news story should present itself. Were hospital administrators acting as bullies? When you think of how bullies behave and the sequellae of their behaviour on their victim — suicide being among them — you have to wonder.

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  1. #1 by Beth Boynton, RN, MS on Friday 13 May 2011 - 1401

    WHAT A HUGE TRAGEDY. As preventable as many medical errors that persist. The organizational systemic factors will continue to perpetuate bullying and/or other disruptive behaviors that are so harmful to professionals, patients and families.

    As a nurse consultant and author I work hard to help leaders create workplace cultures that are safe and positive. More and more I receive emails from distressed nurses or professionals who know a distressed nurse who wants help.

    As a nurse speaker, author, and publisher I have gained a reputation for being a resource in this area and yet wrack my brain to come up with meaningful, timely and affordable ways to help. I offer validation and insights in a pro bono email, and an openness to publish an anonymous qualitative story in my newsletter, availability to act as a coach to navigate workplace issues and often suggest counseling support. Yet I think folks need an option that feels more action oriented and somehow empowering and safe. I am seeking input on an idea I have.
    My idea is to give ‘victims’ or ‘bystanders’ a way to report their concerns to a leader anonymously along with a constructive component that is quick, easy and affordable. Sending a leader a certified letter on my stationary along with a copy of my book might be a non threatening (although somewhat uncomfortable) way to get a leader’s attention with sort of a, ‘someone is watching’ message. I’m posting a draft letter below and would charge about 100 bucks to cover book, postage, letter, time.

    What do you think? email me: bbbboynton@earthlink.net, more about me at http://www.bethboynton.com

    Thanks a lot for your time, comments and work you do,

    Beth Boynton, RN, MS
    Organizational Development Consultant
    P.O. Box 192
    Portsmouth, NH 03802-0192
    http://www.bethboynton.com
    bbbboynton@earthlink.net
    1-207-752-0826

    CEO of ABC Hospital
    1 Hospital Drive
    Anytown, USA

    Date

    Dear CEO or Supervisor Smith,

    I recently received a report of bullying or disruptive behavior involving personnel in your organization, department or unit. I accept reports from any leader, staff, patient or family who express concerns about inappropriate behavior in any healthcare setting. As you know, such behavior is linked to adverse events, morale issues and increased costs.

    Most people who are victims or bystanders of the workplace abuse are afraid to report it. Fears of job loss, retaliation, and/or lack of trust Administration contribute to this destructive silence. Consequently, some leaders may not be aware of ongoing behaviors that compromise safety and hurt employees.

    This letter and a copy of my book, Confident Voices: The Nurses’ Guide to Improving Communication & Creating Positive Workplaces is an anonymous resource-/gift from the person who reported the workplace abuse. It is our hope that it will help you to understand and stop the individual and organizational factors that contribute to horizontal and/or vertical violence in your organization.

    Your role is a critical one in achieving a safe, positive and cost-effective healthcare setting. Thank you in advance for your efforts to identify and end workplace abuse. Please let me know if I can be of any further help in this matter.

    Respectfully,

    Beth Boynton, RN, MS

  2. #2 by Anne on Friday 13 May 2011 - 2143

    I am dismayed by Seattle Kids Hospital action. Fired for making a mistake? It was a terrible mistake, but unless this was a pattern of errors dispite reeducation it was an overreaction. I would be reluctant to report an error if I worked in such an institution. So sad for all parties involved.

  3. #3 by Colin Hung on Saturday 14 May 2011 - 1408

    A nice post that highlights a real problem and I don’t mean just healthcare errors. Too often we forget that nurses, physicians and other healthcare staff are people too. They don’t wake up in the morning and set out to harm someone on purpose – mistakes and tragic errors do happen. It’s unfortunate in this case that the hospital didn’t have a program in place to help all parties involved deal with the trauma of the error. One organization MITSS (www.mitss.org) does just that. If MITSS or an organizaiton like them had been available to the family AND the hospital staff, then maybe this second unecessary death could have been prevented.

  4. #4 by The Nerdy Nurse on Sunday 15 May 2011 - 1112

    This is devastating.

    It is an example of bullying, and likely we are starting to get to the real root of the problem here. Lack of Support. And this lack is staring at the highest levels.
    Words cannot describe how terribly tragic the lost of an 8 month old infant is, but in the same breath, it needs to be stated that words cannot describe the loss of a 27 year veteran nurse…. think of all the 8 month olds lives that she touched, helped, held, nurtured, or perhaps even saved.
    Support is needed. And if a policy is no tolerance. it has to be no tolerance. Meaning the term “situational” should NEVER be apart of the vernacular associated with it!

  5. #5 by Inez Salas on Monday 16 May 2011 - 1452

    What a tragedy, we not only lost the life of a precious little baby but the life of a good nurse who simply made a mistake that could of been prevented. I feel that the punishment must fit the crime and although she made a fatal medication error it was not in my opinion just for her to lose her life. I am saddend to hear she felt the sollution was to take her own life. I understand how overwhelming it must of been for her to deal with this situation and how alone she must of felt to feel like suicide was the only choice. As a nurse I have seen nurses get ostrizisied as a result of reporting errors and fired as a result of their reports. Ofcourse the termination is not “labeled” as medication error there is always “other reasons”. Sadly this is not the first time this story had been discused and even worse we will likely see it again.

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