Newsletter

Medical Error Nurse Suicide

Information for this case was obtained from newspaper accounts. See references for details.

Case

A 10-fold overdose of calcium chloride contributed to the death of an infant on September 19th of last year. According to the family, a nurse accidentally miscalculated the dose. After an investigation, the hospital changed its policy to allow only pharmacists and anesthesiologists to access calcium chloride in non-emergency situations.

Additionally, the nurse, Kimberly Hiatt, who had worked at that hospital for 27 years, was fired. The state nursing board placed her on probation. Ms Hiatt was unable to find another nursing job despite many job applications and inquiries. She took on some construction work.

Hiatt’s mother commented: “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.… [The hospital] had a baby that died. It was the result of a human error. They have to do something. But to me, there were other alternatives than firing someone who had been a good, faithful nurse, and did not have a record as a sloppy nurse.”

The hospital and Hiatt entered into a confidential settlement in the aftermath of the firing. It is not clear what the settlement was. The hospital would not provide details and Hiatt’s relatives are bound by a nondisclosure agreement.

Ms. Hiatt committed suicide April 3rd. Hundreds attended her funeral, including children she had cared for and their families.

Commentary

Even when a patient dies from medical error, the employment response should be based upon the mechanism of error, not the severity of the outcome.

We do not have the information the hospital and nursing board used to make their decisions. An investigation into an individual’s culpability should include questions such as: Was the individual knowingly impaired? Did the individual consciously decide to engage in an unsafe act? Did the caregiver make a mistake that individuals of similar and training would be likely to make under the same circumstances? Does the individual have a history of unsafe acts?

Many errors are not due to recklessness or substandard work, but are the normal slips and lapses that humans always have. And the caregiver is often significantly affected by the error as well. As Dennis Quaid stated in the wake of his twins’ receiving heparin overdoses, “I don’t blame any of the nurses… human error occurs. If I make a mistake in my business, I get a take two. They don’t. And when a mistake occurs, they need help as much as the victims as well, because they’re traumatized by it.”

Any large institution will occasionally find that an employee is unsuitable and will need to fire him. However, in most cases it is the system, not the employee, that failed the patient. In those cases, the system needs fixing, and the employee needs consolation and emotional support. In some cases, where the behavior was not reckless but showed drift outside of safe boundaries without the recognition that the behavior was unsafe, coaching may be useful as well.

Disciplining an employee for a human error does not make a hospital safer, as it does not address the risk for recurrence. Conversely, the discipline may result in reduced ability of the hospital to know of and learn from employees’ mistakes, resulting in missed opportunities to increase patient safety.

References

Kalb C, Quaid D. Dennis Quaid: Making Hospitals Safer. Newsweek. 4/12/2010.

Kang M. Infant dies of accidental overdose at Children’s Hospital.KOMO News. 9/30/2010.

Ostrom CM. Nurse’s suicide follows tragedy. Seattle Times. 4/21/2011.