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Suicide After Medical Error Highlights Importance of Support for Clinicians
It's been more than a decade since "To Err is Human" and the feedback from this story indicates that we're still not learning the message. All humans make mistakes. Our only hope is to design systems that provide enough safety checks that risks to patients are minimized. To do so, we need open, honest feedback about how errors occur and nurses and other clinicians will only do that when they do not have to fear they will lose their jobs and their livelihoods.
No nurse goes to work thinking, "I'm going to harm a patient today." When something bad happens, it's an incredibly emotional experience for all involved.
Gayla Jackson, RN, BSN, a nurse manager of a busy medical unit, knows first-hand what it's like to have the unthinkable happen. About 15 years ago, she was working as a staff nurse on a busy ICU step-down unit when one of her two patients coded. As things began to calm down, she took a telephone order from the physician of her other patient requesting an IV push of heparin.
Jackson says she listened to the order, then returned to the emergency still in progress. Once the situation was stabilized, she went to administer the heparin to her other patient. She drew up 9,000 units and had a coworker check the dosage, per protocol.
After administering the medication, Jackson says she broke out in a cold sweat. She realized the physician had said 900, not 9,000, units. She still remembers the feeling of dread that broke out when she realized what had happened.
"As soon as I did it, I knew it was wrong," says Jackson. "Your whole body just goes cold. You feel like you will faint. Everything stops and everything flashes. You think, 'I can't go on.' How can you even breathe thinking about what just happened?"
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Comments are moderated. Please be patient.
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.
stefani (5/20/2011 at 10:10 AM)
This is even more tragic when we know darn well that a physician causing the death of a patient results in some courtroom time, some hand slapping and then back to business as usual. Licenses are rarely revoked and even when they are, the physician simply pulls up stakes and moves to the next state.
Bill Gustafson (5/14/2011 at 4:50 PM)
What can be said about such a tragedy. Loss of life is always sad and I have never seen the perfect system that eliminates all risk. I have been in administration and now the medical equipment side. Devices, pharmaceuticals, services all have their inherent risk. I agree that somehow we must be responsible yet accept the errors and balance that with the good we do. Supporting those who are the front line in health care should be a given or you will loose those who care in favor of those who don't.