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.

Has Google cracked the secret of how to be a good boss? The data geeks at Google have come to some surprising conclusions about what makes a good manager and the findings can be applied by managers in any industry, even healthcare.

In fact, the news struck me as particularly reassuring for nurse managers, who are so often promoted into the role with no experience in managing or leadership training, then left to sink or swim as they figure out how to manage a whole unit (sometimes more) of nurses. Some are naturals, some are not. But Google's data says, the most important thing for managers to do is just be accessible for employees.

This sounds overly simplistic and it surprised the Googlers, who assumed the best managers would be those with high technical expertise who really understood what their teams were working on and could provide technical knowledge to help that. No. What the teams really needed was someone who was accessible, who could listen and help them figure out the answers themselves. It didn't matter whether the manager had as high technical knowledge as the team, just that they could go to the manager for support.

This is encouraging for nurse managers. They are removed from the clinical side of patient care as they spend much of their days in meetings, thinking about the business side of providing care. They do not need to be the font of all knowledge for clinical issues; staff nurses should have access to charge nurses, clinical nurse specialists, clinical nurse leaders, physicians, pharmacists, or simply the library, for that kind of information. The nurse manager is there for the business side, for running the unit, for strategic thinking, for performance improvement and career development. The most important side of that, from the staff perspective, is taking time talking to staff and being available when needed.

The Google mission to build a better boss was profiled in The New York Times. Back in 2009, according to the article, Google launched a team to analyze employees' perceptions of their managers, who was considered a "good" or "bad" manager, and why.

To do so, they analyzed performance reviews, feedback surveys, and anything else that provided data. Once they started digging into the reams of data, they came to a surprising conclusion. What employees valued were even-keeled managers who helped employees work through problems, rather than imposing solutions, who made time to talk with employees, and who took personal interest in their employee's lives and careers.

Although the worlds of Google and healthcare seem a long way apart, these findings make just as much sense in a hospital setting as in Google's high-tech world. Nursing is a stressful profession, filled with hierarchies and bureaucracy. Managers who care about employees' lives and careers and who are supportive are the managers who will work to remove needless obstacles and create positive workplace environments based on civility and respect.

Google realized that its best managers had employees who performed better and who stayed longer. Helping nurse managers value and spend time on these important topics should achieve the same results.

As healthcare delivery changes, do licensed practical nurses (also known as licensed vocational nurses) still have a role to play in acute care? A growing number of organizations have decided they do not and are actively phasing out the role.

Just last week, local media reported that Schuylkill Medical Center-South Jackson Street, located in Pottsville, PA, decided to phase out all LPN roles within the next six months. LPNs will be encouraged with the aid of existing tuition reimbursement programs to pursue education to become RNs. Another option for the LPNs is to move into nursing aide positions with lower pay.

Across the country, organizations are wondering whether the LPN meshes with the direction acute care delivery is headed. In some areas of the country, staff shortages mean the LPN in acute care cannot be abandoned. However, as healthcare delivery changes and hospitals streamline care delivery models, organizations are acutely aware they will need staff with higher levels of education to provide the nursing care needed by hospital patients.

Moving away from LPNs must be handled with care. Depending on the number of LPNs an organization employs, the move could be contentious if not handled with tact. Some organizations have faced the threat of age discrimination suits from LPNs angry at being pushed out.

Others believe that pursuing designation as an ANCC Magnet Recognition Program® (MRP) facility—a designation of nursing excellence—involves doing away with the LPN. The popular nursing website Allnurses.com has featured discussions where LPNs believed pursuing MRP designation would get them fired. In fact, the MRP program has no requirements for RN-only care models.

“What MRP requires is that there is a role definition for all nursing staff members the hospital utilizes,” says Barbara J. Hannon, MSN, RN, CPHQ, MRP director in the department of nursing at the University of Iowa Hospitals & Clinics. “If you utilize LPNs in a caregiving role in your institution, you must define how this level of provider fits into your care delivery system. MRP hospitals use all kinds of health delivery models, but each one must be laid out in your documentation, along with how each role is filled and how you utilize the State Board of Nursing to define the health delivery roles.”  

“As our patients get sicker and medical care, nursing care, and treatment get more complex, this mid-level provider (LPN) role is not cost effective because there are so many things the state boards of nursing restrict them from doing,” Hannon says. “Because there are so many things they cannot do, our LPNs are included in the unlicensed personnel count. We have to have a full complement of RNs anyway, so it becomes difficult to find a role for them in a hospital with such complex patients as ours to find them something they can do independently.”

This restriction of practice is the biggest reason LPNs are being cut at acute care hospitals. State boards of nursing decide the scope of practice for RNs and LPNs, restricting who may provide nursing assessment and nursing diagnostic decisions. Many states restrict LPNs from dispending medication.

One organization that has successfully moved away from LPNs is North Shore-LIJ, a 15-hospital health system in New York, which dispensed with them in the late 1990s.

“We realized that the acuity of patients in the acute care setting was increasing and that those patients required much more assessment,” says Maureen White, RN, senior vice president/CNO. “We would not be able to rely on LPNs for delivery of those care needs. We assessed it and felt that hiring LPNs in acute care settings would not be advantageous to the delivery of care that we need to deliver.”

North Shore-LIJ planned ahead and let its staff know that within 10 years, it would phase out the role. LPNs were offered the opportunity to pursue their RN degrees, which would be paid for by the organization, or to be placed in non-licensed positions.

“Roughly 75% of the LPNs decided to take us up on the offer to go back to school,” says White. “They achieved their licensure for RN and many of them are currently working with us as RNs.”

“There were some that were toward the end of their careers and we allowed them to stay in their position as LPN knowing that RNs on their floors would have to watch over their patients as well, doing the assessment, diagnostics, interventions etc. As those people retired, we filled those positions with registered nurses.”

The small portion who didn’t fit that category and who did not want to go back to school were helped to find other roles within the organization. White said no one lost a job as the result of the decision and that there were roles that could easily be performed by LPNs, such as dialysis technicians or OR technicians, which are unlicensed roles.

Despite the move away from the LPN in acute care, the role as a whole is in no danger of going away. U.S. Department of Labor Bureau of Labor Statistics predicts LPN ranks will grow by 21% from 2008 to 2018. The bulk of this growth is post-acute care, where patients do not require the skilled assessment and complex critical thinking needed from RNs.

 “I don’t know that it will completely die out because there are areas such as long-term care facilities that can utilize their skill sets,” says White. “In acute care facilities in the foreseeable future, I don’t see the LPN role as being a viable role. There will be smaller numbers required.”

How many quality improvement projects are going on in your organization right now? How many committees are devoted to improving safety? If you're like most facilities, there are probably dozens. Across the country, countless hours are devoted to preventing errors that harm patients through creating checklists, protocols, automated systems, and the like.

Are they worthless?

That's what I started wondering when I came across a new study that examines why poor communication is still the biggest patient safety danger of all.

The report is a combined effort from the American Association of Critical-Care Nurses (AACN) and the Association of periOperative Registered Nurses (AORN) in partnership with VitalSmarts, a training and organizational performance company. AACN and VitalSmarts produced the seminal "Silence Kills" data five years ago that found:

• 84% of physicians have seen coworkers taking shortcuts that could be dangerous to patients
• 88% of physicians say they work with people who show poor clinical judgment
• Fewer than 10% of physicians, nurses, and other clinical staff directly confront their colleagues about their concerns

The 2006 data greatly enhanced our conversations about how to improve safety and led to efforts such as AACN's healthy work environment initiative that has been adopted by many organizations.

Wanting to see what's changed in the last five years, the organizations, joined by AORN, conducted another study that surveyed 6,500 nurses and nurse managers. The data revealed some alarming statistics, released in a report "The Silent Treatment." Eighty-five percent of respondents said a safety tool had alerted them of a problem that might have been missed and potentially harmed a patient and yet 58% percent revealed they didn't say anything about it.

Among the study's key findings:

• More than four out of five nurses have concerns about dangerous shortcuts, incompetence, and disrespect demonstrated by their colleagues
• More than half say shortcuts led to near misses or harm, and only 17% of those nurses shared their concerns with colleagues
• More than a third say incompetence led to near misses or harm, and only 11% spoke to the colleague considered incompetent
• More than half say disrespect prevented them from getting others to listen to them or respect their professional opinion, and only 16% confronted their disrespectful colleague

"Safety tools such as protocols and checklists guard against honest mistakes," says AORN Executive Director/CEO Linda Groah, RN, MSN, CNOR, CNAA, FAAN. "However, this study tells us there is more work needed in the OR to support the surgical team's ability to establish a culture of safety where all members can openly discuss errors, process improvements, or system issues without fear of reprisal."

AACN President Kristine Peterson, RN, MS, CCRN, CCNS, says there has been progress made. "Compared with what we learned in 2005, nurses now speak up at much better rates and are now nearly three times more likely to have spoken directly to the person and shared their full concerns," Peterson says. "This increased focus on creating cultures of safety needs to continue until every health professional feels empowered to speak up to reduce errors and improve quality of care."

Despite the improvements, the "report confirms that tools don't create safety; people do," says David Maxfield, vice president of research at VitalSmarts and lead researcher of "The Silent Treatment." "Safety tools will never compensate for communication failures in the hospital."

This makes sense. What's the point in spending hours training staff to use a checklist or follow certain steps if nurses are too scared to speak up and say something when an error is revealed? This study was a wake-up call for me when thinking about patient safety, despite the fact I hear stories about belligerent surgeons, condescending physicians, and bullying nurses every day.

Just recently I heard a story from Gary Sculli when I spoke to him about implementing techniques from aviation crew resource management in nursing.

"While conducting a CRM session for nurses I asked the question, 'What would you do if you saw a physician about to do something that was going to cause harm to a patient?'" says Sculli. "A nurse confidently said, 'I would tell him to stop'. Then I said, 'What if he or she ignored you and continued?' What the nurse said next astounded me. 'Hey, I told him. It's on them at that point, but I would document what occurred.'"

This is a perfect example of what the study shows. We have a culture where nurses have been ignored, condescended, abused, or generally disrespected for so long that many have checked out and don't want to rock the boat or get into trouble. Or risk being shouted at.

How can any of us be happy about the fact we have a culture where people are so scared to speak up that they willingly let an error happen rather than risk saying something? What will it take to force us to confront the basics? Perhaps we need to stop developing new programs until we figure out a way to communicate?

Physicians and nurses must check their egos at the door and commit to improving the culture and communicating with respect. Without the concerted effort of the complete caregiving team, nothing will ever change. For the sake of our patients, we must empower everyone on the healthcare team so that all are valued and engaged in keeping our patients safe.