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