Suicide After Medical Error Highlights Importance of Support for Clinicians

Rebecca Hendren, for HealthLeaders Media , May 10, 2011

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?"

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7 comments on "Suicide After Medical Error Highlights Importance of Support for Clinicians"

Rudy (7/21/2012 at 9:17 PM)
unfortunately, the culture in nursing lets it happen. Doctors call with orders, lab calls with critical values, family members call with questions/problems/complaints, transportation needs to take bed 2 to xray NOW, and if you make any of them wait, they are going to report you/write you up/ file a complaint/ stand there and yell/ let the phone ring on and on and on. Meanwhile you are trying to decipher a doctor's handwriting, find out what the last calcium level was, what the potassium level is, and what the cardiac monitor is reading (because there has to be a reason the calcium chloride was ordered, was it for high potassium must check EKG) and as you are on the computer attempting to do this, bystanders think you are browsing the internet Suddenly the final distraction happens and a med error is made.

Rudy (7/21/2012 at 9:13 PM)
"unfortunately, we have no idea how the error occurred and how the hospital handled the situation" Yes we do. She administered 1.4 grams of calcium chloride [INVALID] instead of the correct dose of 140 milligrams, which contributed not only to the death of the 8-month-old, but also to her firing, and a state nursing commission investigation.

Steven D. Hobbs, Ph.D., R.N., BC (5/23/2011 at 1:36 AM)
My heart goes out for the child, the parents, the nurse, her family and the facility involved. The facility is most to blame here. Obviously they chose the low road response. How likely is any nurse at that facility to now report an error? What does it say about their "support of nursing?" An excellent example as to why EVERY R.N. needs their own independent malpractice insurance (although this will not save your job, it may save your home). I hope they are not a Magnet facility.




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