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ADVANCE Perspective: Nurses

Twin Tragedies

Published July 24, 2012 2:52 PM by Robin Hocevar

The nightly news has moved on from the story of Kimberly Hiatt, the Colorado nurse who committed suicide after accidentally overdosing and killing a baby. But for nurses, the potential for living this nightmare lives on.

After making the first mistake in her 24-year career and dispensing 1.4 grams of calcium chloride to an 8-month old at Seattle Children’s Hospital, Hiatt was fired and became the subject of a state nursing commission investigation.

Though uncommon, Hiatt's story could be the undoing of any nurse. According to an articles in the Archives of Surgery, surgeons who believed they made medical errors were more than three times as likely as their counterparts to contemplate suicide.

Hiatt cared for the fragile baby from birth and was even Facebook friends with the parents. Though they never sought damages, they requested her removal from the child’s case.

Her employer follows the Just Culture model, which recognizes the need to correct systems instead of penalize individuals. Officials at Seattle Children’s Hospital have said other factors were considered in Hiatt’s termination.

Since her dismissal and subsequent death, the Washington State Nurses Association, grieved the case and negotiated a confidential settlement on her behalf.

Hospital officials said they've since changed protocols for administering calcium chloride. Every day, new technological innovations add new safeguards to protect against thoughtless error.

Nurses, do the new dispensing equipment, better organized protocols or electronic checklists make you feel any more confident that Hiatt’s story won’t happen to you?


This doesn't sound like the Just Culture Model to me. They fired her after she made this mistake. It was tragic but does the 24 years that she has worked and cared for fragile infants without a mistake count for anything? Instead of firing her, the hospital should have sought psychological help for this nurse and allowed her to work in a less stress-filled area. This nurse could have also gone on speaking assignments to nursing schools and other hospitals in helping to educate others not to make the same mistakes and help improve nursing practice. This was a double tragedy which ended up in the deaths of two individuals.

Debra August 8, 2012 1:25 AM

I  imagine this nurse had too much happening concurrently to follow all the safe-guards to prevent this accident.  Too many complicated assignments is the leading cause of errors as well as HAIs thus spreading the risk for errors and infections.  Nurses must be legally free to reject an assignment that is more than they can handle without losing their jobs.  

Joanne Thompson, BSN, pedi home care - nurse, Bayada August 1, 2012 11:23 AM
Lansdale PA

Scanning, checklists, etc. are all put into place to help prevent error.  But the biggest error is being overloaded, in a hurry, and bypassing any or all of the safety nets put into place.  There are still "work arounds" for most safety nets that are out there, even the electronic ones. When we use them for the most part they work.   In other words there is always room for improvement.  When we bypass them it can become simple human error, and what is the defense?  

Sue, NICU - supervisor August 1, 2012 9:20 AM

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