Suicide After Medical Error Highlights Importance of Support for Clinicians

Rebecca Hendren, for HealthLeaders Media , May 10, 2011

Jackson said that when she heard about the story in Seattle, her first thought was about the parents of the baby.

"My gut reaction was, because I am a mother, first for the baby and parents," she says. "As a mother, I'm thinking how it would feel to lose a child. There are no words for the parents of the baby. But then, obviously, you relate to the feelings of the nurse. After I processed those feelings, I put myself in the position of the nurse, because I've been in that position. There is no feeling on the face of the earth like being a nurse and having the capacity—unintentionally—to harm somebody."

Jackson said she received a great deal of support from her colleagues and from her organization, which even back then had a "no blame" culture and sought to learn from errors. She was fortunate that the error was realized immediately, allowing swift prescribing of a heparin antidote and the patient recovered. 

Jackson says much has changed in patient care since she made that error, including introduction of read back protocols and electronic medication administration records that allow scanning and verification of the correct patient and medication. All such processes mean her error is much more likely to be caught now before it ever reaches the patient.

Since becoming a manager, Jackson has had staff under her watch make errors. "By the nature of how many times nurses administer medications and perform tasks, hundreds upon hundreds a week, at some point in everyone's history, you will you make an error," she says. "When you make an error, you always remember what you did wrong."

"I've heard people say we have to fire someone for an error," Jackson says, but her organization wants to encourage openness of errors, particularly near misses, so it can work to ensure they don't happen again.

Jackson says after an error has occurred, the organization provides ongoing emotional support to the nurse, not just immediately following the incident, but over the course of weeks and months. Depending on the situation, the nurse may be provided further education, or perhaps put back in orientation and given more supervision for a period of time.

Cole Edmonson, vice president of patient care services/CNO at Texas Health Presbyterian Hospital Dallas, says it's important for organizations to respond to errors in a way that doesn't impart blame. When an error occurs at his organization, they first try to understand what happened from a systems and personal choice perspective, all done within a supportive and caring environment.

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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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