Medicine Magazine

A Medication Error Leads to Suicide

By Torontoemerg

A nurse commits suicide:

Kimberly Hiatt, 50, a longtime critical-care nurse at [Seattle Children's Hospital], took her own life April 3. As a result, the state’s Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant’s death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt’s mother.

“She absolutely adored her job” at Children’s, where she had worked for about 27 years, said Crum. “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.”

Is it just for a nurse to be fired for a medication error, even if lethal? Most hospitals do have procedures in place to deal with such errors, aimed at discovering the root causes of mistakes in order to improve patient safety. A key part of this process is to encourage nurses to report medication errors and even near-misses without threat of retaliation or disciplinary measures, but instead to offer education to strengthen skills and critical thinking. The hope is that in doing so, flaws in the process of drug administration can be easily identified and corrected.

Unfortunately, such an arrangement requires a certain degree of trust between management and the front line. When I worked in the U.S., management decided to implement a “No discipline, no retaliation” policy for medication errors. When the ED manager was asked if there actually would be no discipline taken for medication errors, she laughed and told us it would be “situational.” You can guess how successful the new policy was. Once trust is lost between front line nurses and management, it’s difficult to restore.

Firing a nurse distracts from actually promoting safety in a meaningful way, and diverts attention, as Kevin Pho points out, from where responsibility ultimately rests for ensuring safe medication practices: the senior management. Hospitals will fire nurses in the mistaken belief that removing a nurse who has committed a lethal error — an easy target, at that, if truth be told — will somehow reduce risk and liability and demonstrate commitment to patient safety. In fact, the precise opposite is true. By disciplining nurses who commit errors, and by not engaging in remediation with these nurses,  a climate is created where errors, if they occur, are likely to go unreported and unresolved — and substantially increasing risk.

It it enormously tragic a 8 month-old child died as a result of a medication error. And to be clear, none of this evades the ultimate responsibility of the RN to administer medications correctly. It’s important to note the state nursing board imposed substantial sanctions on this nurse, just prior to her suicide, including a requirement to be supervised while administering medications for four years.

Yet it’s also tragedy multiplied that the Seattle Children’s Hospital saw fit essentially first to scapegoat her, evading its own responsibility, and then to drive a 27-year veteran from the profession, leading to the point where she saw no other option but to kill herself. It’s interesting, in the context of the discussion around bullying this week in the nursosphere, that this news story should present itself. Were hospital administrators acting as bullies? When you think of how bullies behave and the sequellae of their behaviour on their victim — suicide being among them — you have to wonder.

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