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Suicide After Medical Error Highlights Importance of Support for Clinicians

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   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.

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?"

Jackson said that when she heard about the story in Seattle, her first thought was about the parents of the baby.

"My gut reaction was, because I am a mother, first for the baby and parents," she says. "As a mother, I'm thinking how it would feel to lose a child. There are no words for the parents of the baby. But then, obviously, you relate to the feelings of the nurse. After I processed those feelings, I put myself in the position of the nurse, because I've been in that position. There is no feeling on the face of the earth like being a nurse and having the capacity—unintentionally—to harm somebody."

Jackson said she received a great deal of support from her colleagues and from her organization, which even back then had a "no blame" culture and sought to learn from errors. She was fortunate that the error was realized immediately, allowing swift prescribing of a heparin antidote and the patient recovered. 

Jackson says much has changed in patient care since she made that error, including introduction of read back protocols and electronic medication administration records that allow scanning and verification of the correct patient and medication. All such processes mean her error is much more likely to be caught now before it ever reaches the patient.

Since becoming a manager, Jackson has had staff under her watch make errors. "By the nature of how many times nurses administer medications and perform tasks, hundreds upon hundreds a week, at some point in everyone's history, you will you make an error," she says. "When you make an error, you always remember what you did wrong."

"I've heard people say we have to fire someone for an error," Jackson says, but her organization wants to encourage openness of errors, particularly near misses, so it can work to ensure they don't happen again.

Jackson says after an error has occurred, the organization provides ongoing emotional support to the nurse, not just immediately following the incident, but over the course of weeks and months. Depending on the situation, the nurse may be provided further education, or perhaps put back in orientation and given more supervision for a period of time.

Cole Edmonson, vice president of patient care services/CNO at Texas Health Presbyterian Hospital Dallas, says it's important for organizations to respond to errors in a way that doesn't impart blame. When an error occurs at his organization, they first try to understand what happened from a systems and personal choice perspective, all done within a supportive and caring environment.

"We operate from a belief that no one intends for errors to happen or seeks to create errors," says Edmonson. "Instead we realize it is often a complex interaction between the culture, the systems, the processes, and the people in an organization. We respond by thanking the person who reported the error, seeking to comfort those involved, seeking the truth of the situation, rebuilding trust among the team, and finding solutions, both people and process based, to mitigate further risk."

THPHD draws a distinction between human error, at risk behaviors, and reckless behaviors when examining what went wrong and the reasons behind it. Edmonson says errors and all variances should be systematically addressed through just culture algorithms for consistency, completeness, categorizing, and actions to be taken post analysis.

"One of the most difficult tenets of a true just culture is to not focus on the outcome of the behavior, but rather seek to understand the personal decisions, system influence, and context in which the decision was made, which helps us to address the real issues," he says. "It is very possible that two people can commit the same error with very different outcomes, so we have to ask ourselves from a just culture perspective, is one more egregious than the other because of the outcome?"

In light of the Seattle story, this is a pertinent question to ask.

"Removing the outcome bias, the fear of reporting, and having leaders that clearly understand how to operate in the just culture and to support staff is the best path to a reporting of errors," adds Edmonson.


Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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