A tragic story about the death of a child from a medical error turned even sadder last month after the nurse who administered the medication took her own life.
In September last year, a critically ill infant, Kaia Zautner, died at Seattle Children's Hospital, in part due to an overdose of calcium chloride.
The nurse who administered the medication, Kimberly Hiatt, was first put on administrative leave and then dismissed. According to news reports, Hiatt had 27 years service at Children's Hospital and the error was categorized as a "calculation error."
According to Hiatt's mother, in an interview with The Seattle Times, the incident was investigated by state disciplinary authorities and Hiatt agreed to a fine and to four years of probation, including the requirement that if she took another nursing job, she would be supervised when she gave medication.
The hospital has declined to provide details of the incident, saying it can't discuss personnel matters. So unfortunately, we have no idea how the error occurred and how the hospital handled the situation. We do not know for sure the reasons why Kimberly Hiatt committed suicide last month, although in news reports family and friends blame the tragic error and its aftermath.
While we can only speculate about this case, the sad story should be a wake-up call for how hospitals deal with clinicians after errors. At a time when one in three hospitalized patients experience a medical error, a horrifying rate that must be reduced, it is paramount that clinicians feel they can be honest and open when errors occur, and even more importantly, that they speak up after near misses, which so often are never mentioned. To learn how errors occur and how to prevent them, we must have open and honest communication.