To Err is Human: Medical Errors and the Consequences for Nurses

The Neonatal Intensive Care Unit.
Image via Wikipedia

That medical care can be harmful to your health or even deadly, is not necessarily news to many people. The extent of it within the US health care system and the impact of it on health care providers are not well known. The IOM Report To Err Is Human: Building a Safer Health System (2000) highlighted serious patient safety issues in our health care system and outlines approaches to patient safety improvement. This report emphasized that the vast majority of adverse patient events were the direct result of bad systems and not of bad health care providers. “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” They pointed to the aviation industry as a model for safety design at the systems level. Root cause analysis was applied to understand and try to prevent adverse events. “Never events” were identified as sentinel patient safety events for monitoring purposes in hospitals (these include surgical removal of the wrong body part and inpatient suicides). National level patient safety monitoring databases were developed. Eleven years later where are we in terms of progress on patient safety?

In the April edition of the journal Health Affairs, indications are that we have not improved much and may actually have worsened. A study by Classen, et al reveals that serious preventable adverse events occur in one out of every three hospital admissions. Another study estimates a $17.1 billion annual cost of measurable medical errors in the US.  They point out that the risk of harmful errors in health care in the US is increasing due to the increasing complexity of care and of medical devices and medications. What to do about this? The Agency for Healthcare Research and Quality is putting an emphasis on educating patients on ways to advocate for their own patient safety (or parents of pediatric patients). But as Donald Berwick points out in the April 15th Health Affairs Health Policy Brief on improving quality and safety, “Commercial air travel didn’t get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too.”

I have been thinking about the issue of patient safety and the consequences for nurses because of the recent news of the suicide of a respected local RN, Kimberly Hiatt. She died April 3rd at the age of 50. She had worked as a NICU nurse at Seattle Children’s Hospital for almost the past thirty years. I did not know her personally, but by all accounts she was a devoted and highly capable and compassionate nurse. In fact, Megan Moreno, a pediatrician who did her fellowship at Seattle Children’s Hospital and whose daughter Fiona died in the NICU of congenital health problems describes Kimberly Hiatt in an article published in the Archives of Pediatric and Adolescent Medicine (January 2006). She writes, “Our favorite nurse was assigned to us the next day, and she helped us through the difficult task of extubating Fiona.” At the end of the article she expresses particular gratitude to Kim Hiatt, RN, along with her neonatologist.

Kimberly Hiatt committed suicide because of a cascade of adverse events that happened to her in the aftermath of a medication error that resulted in an infant’s death in the NICU at Children’s. This happened in September, 2010 just months after a highly publicized death of a 15 year old autistic boy after routine dental surgery at Children’s, which resulted from an incorrect dose of a Fentanyl patch (a powerful narcotic) prescribed by the dentist. Children’s Hospital changed its policies on the prescribing of narcotics after this incident, but the dentist was not disciplined. Around the same time, an ER doctor at Children’s incorrectly administered a drug to a critically ill patient by IV instead of by an injection in the muscle, and the patient had to be transferred to another hospital because of the complications. The physician was not disciplined.

In contrast, Kimberly Hiatt was fired soon after the infant’s death. Also soon after the infant’s death, Children’s Hospital changed its policies to require stricter control and checks on the administration of the specific medication, calcium chloride, which is considered an especially dangerous drug  in medically fragile infants.  Dr. Hanson, the Medical Director of Children’s Hospital said that it was important that all staff feel safe to report mistakes. The Washington State Nursing Commission put restrictions on her nursing license with a four-year probationary period; with these restrictions no one would hire her to work as a nurse. According to a Seattle Times article (4-20-11), many hundreds of former patients and their family members, as well as nursing colleagues attended her funeral. In the Seattle Times Editorial and Opinion pages today, F. Norman Hamilton, a retired anesthesiologist writes, “The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error. (…) If we fire every person in medicine who makes an error, we will soon have no providers. (…) It is my belief that if the nurse had been dealt with appropriately—with compassion and insight—that she, today, would be a valuable and happy nurse.”

So I am left with many questions. Why was the nurse treated so differently from the   dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes—and usually due to unsafe staffing levels they have no control over—what do I teach my students to do? If the suicide of a hospital patient is considered a sentinel “never event,” shouldn’t the suicide of a nurse such as Kimberly Hiatt due to systems errors be considered a “never event?”

22 thoughts on “To Err is Human: Medical Errors and the Consequences for Nurses

  1. Thank you for this article. Will you please post a direct link to the Seattle Times article? I have searched online for days on this topic, and have found nothing but the King County death notice. Kim took care of our daughter in the ICU and I have nothing but good memories of her. I am shattered at her passing.

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  2. Hi Karen,
    Thank you for the suggestion and I’ve now made the direct link. As I did the link it struck me of the irony of the title of the Seattle Times article: “Nurse’s Suicide Follows Tragedy” as if her suicide weren’t part of the tragedy? I am hearing directly from many people that they share your feelings…
    Josephine

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  3. I know more about this particular situation than I am able to discuss, but I can say, unequivocally, that you do not have the full story. It saddens me when anyone feels like they have to take their own life, and leaving a family behind to deal with the fallout is even more heart wrenching. However, Kim was supported by a very strong union, one that would not allow a nurse to be fired for a mistake that boiled down to a calculation error. Anyone that has worked with the union on disciplinary matters know that they do an excellent job of protecting the rights of their nurses. Only when presented with solid evidence would they allow anyone to be let go. I understand that when looking at this situation and comparing it to others it looks like some injustice has been done, but there is much more to this story that I feel just cannot be told. In the end we are faced with three tragedies, first a family lost their child, and second a family lost a partner, and a community lost a nurse. In this case, finding the truth may be more painful to those that have already been hurt rather than uncovering some injustice in the system.

    I know that you may be able to not allow posts to be viewed. I just ask that in this case you allow this post. It is important to understand that there are more sides to every story even if some cannot be told.

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    1. Thank your for your note pointing to the ‘unkowns’ (probably ‘unkowables’) and complexities of this case, and the role of union support for nurses. As I mentioned in my first post on this, I did not know Kim Hiatt directly and I am only responding to information that is publicly accessible. As such, my questions remain. As does my support for nurses and our health care colleagues to pull together to do better for patient safety. An essential component of patient safety is a healthy work environment for nurses and others on the health care team. That is part of ongoing health care reform.

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    2. No doubt that there is more known than can be said but without further information, others draw the same conclusion and therefore will act based on what they know. Secrets don’t contribute to root cause analysis which is necessary to resolve systems defects. The airline example is right on. If painstaking attention to detail is put forth to prevent loss of life during travel, why not in medicine?

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  4. I think that in the spirit of moving forward from this tragic event, it is important to consider possible consequences and new barriers that can be done to prevent similar errors. One of the most profound is on Paul’s blog, where he cites a culture of silence. I am sad to say, but this event shows how that culture fails all of us. I am concerned about the staff working environment now. With a perceived disparity between physician and nursing punishment will they report errors? Has open communication been fostered or hindered? Will the perceived handling of this by leadership result in a more or less safe institution? I emphasize perception here because it is in my opinion more important than reality. If I go to bed at night knowing I took the correct action, but those who perceived it differently are in a less safe institution, I don’t think in the morning I will have slept very well.

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  5. Anon, so much of what you have written is confusing to me. It comes across as if to say Kim was guilty of some transgression. She is gone. There is nothing productive about that innuendo.
    If she was guilty of some type of behavior that would have put her patients at risk, then why didn’t the hospital, or the union for that matter, do something before she made a fatal mistake? Shouldn’t they be held responsible? Are you inferring that it was just a coincidence in the timing of her dismissal from her job and the fatal medication miscalculation that was all over the media?
    Also, your statement ” Kim was supported by a very strong union, one that would not allow a nurse to be fired for a mistake that boiled down to a calculation error” doesn’t hold true.
    Unions don’t hire or fire employees. The union can do absolutely nothing to help a nurse if they are breaking protocol or hospital policy. I would venture to say that the hospital justified their actions in dismissing Kim from her job because she wasn’t following hospital policy when she failed to follow one of the “5 rights” of medication delivery. The media exposure was no doubt making them nervous. Pure tragedy.
    There are plenty of nurses out there practicing who are a little bit distracted, a tad overworked, a lot understaffed, and a whole lot human who make mistakes all of the time, but they are just damn lucky no one dies when they do it. Kim’s luck had run out, I suppose. It could have been any of us. Union or no union representation.
    I believe unions for nurses have become part of the problem and less of the solution. Physicians do not have unions. They are professionals. They don’t need unions. There were no union reps running to the aid of the ED physician who made the IV vs. IM medication error (another failure of the “5 rights”). That physician, another Children’s Hospital employee, didn’t get dismissed from his job.
    Is this double standard a coincidence? Probably not.
    Nurses are not laborers. Nurses are professionals and we must start respecting each other as such and doing a better job of supporting each other. By that I mean speaking up for what is right, not filing a grievance because you feel wronged by the institution.
    If we believe we are powerless without unions, then the entire medical team, our patients, the families of our patients, the general public, and we ourselves will start to believe we are powerless. It is time to turn that around.
    It’s time we start being realistic about the limitations of our human bodies and minds amidst this great technology and advancement in science. At the root, we are still vulnerable human beings.
    All Kim wanted was her job back. I think she felt the need to somehow repent her error by getting back to doing what she did so well for 26 years…..saving lives and comforting the sick. She was the first person to admit her mistake. She believed she was working in a just culture; that she wouldn’t be punished for her error.
    Would she be alive now if she had just kept her mouth shut?

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  6. I agree Seattle RN. What a devastating loss & tragedy. Kim was a close friend of mine. Thanks for your post. Many heartfelt thoughts and prayers for all of her former co-workers.

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  7. Kimberly Hiatt is Gus Meins (he killed himself due to accusations of sexual abuse among children) of Nurses. Hiatt killed herself to escape the tragedy.

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  8. Thank you for this article. I just lost my job as an LPN for a medication error I made. I am petrified of what is going to happen to my patient, my license, my family and in the end me. I am newly graduated and a new nurse, I don’t know what my next step is. I asked my former boss if I needed a lawyer, she said that they wouldn’t hang me out to dry. I’d like some input on what I should do next.

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  9. The problems related to medical error, disclosure, just culture, and second victims is complex indeed. I am currently in the MN program at UW Bothell and I’ve designed my masters project around this topic (you will speaking to our class Feb 15-so excited to host you!). My employer is implementing a program for error disclosure to improve patient safety. But first, there is so much work to be done in changing a culture that is deeply entrenched. One will not happen absent the other. I’m intrigued by the cultural brew that allows bad practice to persist in this area. I’m hoping you will be able to talk about this a bit in your presentation to us.

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    1. Thanks for your comments Kathleen and for taking on this issue both in your MN program and at your work site. It’s all really about authentic, enlightened and effective leadership “from on high.” Unfortunately, in our current health care system, that type of leadership is rare and far between. If you haven’t read it already, check out my longer (and heavily researched) blog post “Not Just Culture” from 11-11.
      This is a topic I am passionate about, so I look forward to visiting and talking with your class next month.
      ~Josephine

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  10. I’ve been reading some of Kathryn Schulz’s blog on “being wrong” (Ted talk: http://www.youtube.com/watch?v=QleRgTBMX88 ) and trying to better understand the challenges of addressing error in healthcare. She also has a fascinating blog on the “Innocence Project” that I am still reeling from reading. The human need to “be right” and our inability to recognize error (let alone admit it) figures into the healthcare equation at every level.

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