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Suicide After Medical Error Highlights Importance of Support for Clinicians

Rebecca Hendren, for HealthLeaders Media, May 10, 2011

A tragic story about the death of a child from a medical error turned even sadder last month after the nurse who administered the medication took her own life.

In September last year, a critically ill infant, Kaia Zautner, died at Seattle Children's Hospital, in part due to an overdose of calcium chloride.

The nurse who administered the medication, Kimberly Hiatt, was first put on administrative leave and then dismissed. According to news reports, Hiatt had 27 years service at Children's Hospital and the error was categorized as a "calculation error."

According to Hiatt's mother, in an interview with The Seattle Times, the incident was investigated by state disciplinary authorities and Hiatt agreed to a fine and to four years of probation, including the requirement that if she took another nursing job, she would be supervised when she gave medication.

The hospital has declined to provide details of the incident, saying it can't discuss personnel matters. So unfortunately, we have no idea how the error occurred and how the hospital handled the situation. We do not know for sure the reasons why Kimberly Hiatt committed suicide last month, although in news reports family and friends blame the tragic error and its aftermath.

While we can only speculate about this case, the sad story should be a wake-up call for how hospitals deal with clinicians after errors. At a time when one in three hospitalized patients experience a medical error, a horrifying rate that must be reduced, it is paramount that clinicians feel they can be honest and open when errors occur, and even more importantly, that they speak up after near misses, which so often are never mentioned. To learn how errors occur and how to prevent them, we must have open and honest communication.

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7 comments on "Suicide After Medical Error Highlights Importance of Support for Clinicians"


Rudy (7/21/2012 at 9:17 PM)
unfortunately, the culture in nursing lets it happen. Doctors call with orders, lab calls with critical values, family members call with questions/problems/complaints, transportation needs to take bed 2 to xray NOW, and if you make any of them wait, they are going to report you/write you up/ file a complaint/ stand there and yell/ let the phone ring on and on and on. Meanwhile you are trying to decipher a doctor's handwriting, find out what the last calcium level was, what the potassium level is, and what the cardiac monitor is reading (because there has to be a reason the calcium chloride was ordered, was it for high potassium must check EKG) and as you are on the computer attempting to do this, bystanders think you are browsing the internet Suddenly the final distraction happens and a med error is made.

Rudy (7/21/2012 at 9:13 PM)
"unfortunately, we have no idea how the error occurred and how the hospital handled the situation" Yes we do. She administered 1.4 grams of calcium chloride [INVALID] instead of the correct dose of 140 milligrams, which contributed not only to the death of the 8-month-old, but also to her firing, and a state nursing commission investigation.

Steven D. Hobbs, Ph.D., R.N., BC (5/23/2011 at 1:36 AM)
My heart goes out for the child, the parents, the nurse, her family and the facility involved. The facility is most to blame here. Obviously they chose the low road response. How likely is any nurse at that facility to now report an error? What does it say about their "support of nursing?" An excellent example as to why EVERY R.N. needs their own independent malpractice insurance (although this will not save your job, it may save your home). I hope they are not a Magnet facility.