I can't even imagine being a nurse or doctor. I'd hate to have that responsibility of another person's life in my hands like that. I make mistakes just cooking! I agree though, if this was her only mistake and she reported it immediately, then the punishment of being fined, on probation and taking classes seems appropriate. If she was distracted because of a co-worker, then that process needs to be fixed.

@Brenda & ForPosts,

I was fully expecting a lynch mob under this post and must say it was refreshing to find that the first 2 posts were reasonable, rational and logical. As an ex EMt who practiced for nearly 8 years, I got lucky enough to make it through those years with my actions being called into question only once. It was for driving lights and sirens 1 block the wrong way down a one way with a patient in cardiac arrest. I didn't hit anything or hurt anyone but my supervisor didn't like what I'd done. When he questioned me on it, I said considering brain death begins after 4 minutes if you were in cardiac arrest would you rather I went 1 block the wrong way and got you to the hospital in 3 minutes, 45 seconds or go 6 blocks the right way and got you there in 7 mins 45 seconds (NYC traffic)? He signed of on my call report and didn't say another word.

The truth is there a many errors that occur daily in the medical field. Very scary but currently the only way to eliminate errors completely is to remove humans from medical practice.

It is beyond tragic when a genuine error results in the death of someone's loved one, more tragic is when there is a medical professional willfully disregarding policies and good medicine and causing complications and deaths. This nurse made her error known and more than likely was fired because it was just the opportunity the administration needed to rid themselves of someone they did not like. Tragic for the family of the baby and for the family of the nurse.

I feel for the nurse's despair. Unfortunately, Hospitals and other healthcare organizations are always more concerned about dollars and not getting sued, so they're going to be uber-sensitive to keeping someone with such a serious mistake on their staff, for fear of getting uber-sued, should that person commit another critical mistake.

As much as I believe in second chances, it's really hard to give them in such circumstances as pediatrics and NICU. Perhaps a better course of action wouldve been to reassign her to a different specialty that she could do less damage in, then maybe allow her to prove herself back into NICU after X amounts of years. Unfortunately, the lawyers and insurance companies are not as forgiving as the general public.

On a different note, Doctors mostly all have some level of a God complex. They're all trained and nurtured in environments to give them the utmost confidence in their abilities. You can't afford doubt in the middle of an emergency. However, at the same time, overconfidence can lead to doom too. I've worked in the business in several capacities over the year, and know how narcissistic doctors can be about their abilities. Every time one of them committed a mistake, the responsibility was always passed off to a non-licensed personnel, who the hospital could afford to terminate without much ramification. The doctor gets no mark on their record, their malpractice insurance stays the same, the hospital keeps their high-paid doctor, minus a low-paid tech.

None of it is fair. However, both doctors and nurses are paid very well for the licenses they carry, and double-edged sword should tell them it's very easy to lose as well. SO, they need to prepare for a life without it as well.

Brenda and ForPostsOnly - the article states that "Officials at Seattle Children’s Hospital declined to discuss specifics about Hiatt’s termination, although they said there is “more behind Kim’s case than can be made public” because of personnel and privacy policies". Maybe this was her first major mistake, but the implication of the article is that there were other issues related to her performance that were involved. Maybe she had been on the verge of making a major mistake for a period of time but had managed to avoid it. She might not have made the error if she had not been talking to someone else. If she had converted 140 milligrams to grams on paper rather than in her head, perhaps she would have realized that she was off by one decimal place. Those two actions alone suggest that she might have been getting sloppy in her work.

She was Facebook friends with Alana Zautner, Kaia’s mom, hospital officials said.

Has it really come to the point that being a Facebook friends speaks to one's character, integrity, job qualifications, etc.? Pathetic! The writer of the article must be 15.

How utterly sad, and on so many levels.

Suffice to say, no one, but no one ever made a mistake "intentionally".... and especially, after 25 yrs of a perfect record. UGH!!

As it was already mentioned..... no one person is perfect, as we've all crossed that line, at least one time in our lives..........

That poor woman and poor family--prayers are being sent up for all. I saw this reported on our Seattle news. It saddened me then and saddens me again. The inference(s) made by Children's Hospital during this very dark time are startling and disturbing; almost as though to provide justification and further implying that they had (more) ground for her dismissal after two and a half decades of service to the ill and infirmed.

I am so done with emloyers who (ie: human resources workers and a bevy of liability lawyers), while in the healthcare profession, still find room to pound the final nail where there has been so much loss. Gotta look at the 'corporate numbers' when they're asking for more contributions from the public.

What an unfortunate story. It sounds like the world lost a good nurse that made one mistake in 25 years....yes, it was awful and cost a life, but how many lives did she save?

The bureaucracy of the hospital adminstration staff should be held accountable. Do you really think they cared more about the poor family that lost their child or the lawsuit?

Hospital's fault for not having procedures for double checking dosages before administering to critically ill patients.

A lesson to be learned here would be to have doses of medications checked by a second nurse or physician before being administered. Hospital staff are frequently overworked and stressed and two people are less likely to both make a mistake if they check each other's work.

But maybe that's too simple a solution.

I'd be interested to know how long she'd been on duty when this happened and how many hours of sleep she'd had that week. Not assuming that was an issue in this case, but I generally find it interesting that hospital administrators will often do just about anything to prevent lawsuits Except actually hire adequate staff and give caregivers reasonable schedules with enough time for Sleep, decompression, and some semblance of a life.

Dosing administration has safeguards built in:

1. The right patient ( why wristbands are checked now before giving meds.)

2. The right time

3. The right route ( I.V. push, by mouth, IV into a hanging bag, usually of saline, etc..)

4. The right DOSAGE

5. The right drug

But, being human, we make mistakes. I never came close to killing anyone when I worked as a nurse, but I had a couple of close calls on med. administration. IF YOU PRACTICE LONG ENOUGH, IT WILL HAPPEN!

This poor soul obviously had more going on in her life than just this error. And as sad as her death is, it is also traumatic for her children and partner.

I'd have to see the patient records to even have an opinion on whether or not her drug error contributed to this child's death. But going to get out my Mosby's (drug) & see what the range is for Pediatric Calcium Chloride dosing.

Would she had been fired if she was a doctor?

chiach5...So how do you expect anyone to go into a care field if they must be perfect or risk prosecution. She made a tragic error, note she was not prosecuted because they could not state conclusively that her error is the specific reason the child died.

Unfortunately, many people made errors. She made the greatest error by ending her own life. Her partner and her parent made an error by not seeing the depth of the depression she was in and insisting she seek professional mental heath care.

The ones who will suffer are her children because now they are left to speculate as to why their mother killed herself rather than finding a way to cope and moving on. It seems very easy for her partner and her parent to say it was the hospitals fault when she can neither confirm nor deny.

Honorable thing? Am I seeing this correctly. She did the honorable thing by killing herself because she took another life? Oh so let everyone who has ever accidentally killed another human being whether it be in the medical profession, or in a car to kill themselves because it would be the "honorable thing". How pathetic!!!

Unfortunately, as has been said, we live and especially work in an environment in this country that does not accept mistakes or less than perfect performance. As a manager for over 17 years, I have witnessed this evolution in the workplace first hand. Employers are increasingly demanding perfection from employees to the point workplace stress can become unbearable. I have been forced by my superiors several times to terminate employees for the slightest of infractions or simple lapses of judgement that caused no real harm to the company or themselves. If we continue to become such an unforgiving society, then I fear where we are headed.

Honorable? To leave her own two children without one of their parents--weren't the nurse's kids innocent, too? Do you not know anyone who has ever been involved in an accident, either on the receiving end or the causation end? I believe "mercy" is as strong a word as "honor".

She has her life to do with as she pleases. Her children grew up. It was either to do the honorable thing or to avoid the stress of a civil trial on her family. In either case she chose to do with her life, as she saw fit, it may have been selfish, but it was her choice... Maybe she could not live with the guilt. This was not an accident, this was an error.

They said the hospital has since 2007 followed a so-called “Just Culture” model, which recognizes the need to use errors to identify and correct systemic problems, rather than focusing on penalizing individuals.

I ask, why wasn't there a second pair of eyes while setting up for and administering the medication? Sounds more like a procedural error which would make the hospital responsible. A culture of measuring twice and administering once, not to mention better handwriting, would be quite effective in avoiding errors such as these. The baby died 5 days later and the overdose mistake can not be directly attributed to the baby's death. Sounds to me that the hospital knows about procedural issues and is running for cover while placing the blame on one person.

To Wakehead 1.15: You bet your life the hospital would have gotten rid of the dr if he was one who insisted on good care, pointed out failings of the hospital and its nurses, was labeled "disruptive" for pointing these things out, and was not a member of "the boys," that small group who have sold themselves out to the hospital administration.

For RLC1111: So, was there cancer visible on the visits to the first doctor, or not? Your belief that drs will not testify is incorrect. If there is clear-cut action below the standard of care, a dr witness can be found.

This sad tragic case shows the personal involvement that most doctors and nurses have with their patients, their personal responsibility, and anguish if something bad happens. On the other hand, there is a pool of malpractice lawyers out there who are waiting for any bad result...not even an error or malpractice...so that they can parade a damaged patient in front of a jury of 6 people who have never been to medical school, get a verdict for their client, and keep a third of the money for themselves (see John Edwards, upstanding young politician, who made over $30 million for himself suing drs and hospitals).

Too bad the hospital did not support her...and we are left to wonder what else, and if it is valid, the hospital refers to as it degrades her.

And, as often, there is the reference to the "Institute of Medicine" study of 1999...a study refuted within months of its publication in The New England Journal of Medicine, which took about 180 patient deaths from New York hospitals in 1984, the year they studied, and extrapolated it to 98,000 deaths for the entire country.

They got rid of her because the ensuing lawsuit prevented them from doing anything else. After all, they couldn't look incompetent.

There is no loyalty by employers. Not any more. Twenty five years and no one stood by her. This is such a sad story.

chiach5---Your accounting errors could land your butt in jail.

RLC1111---You made errors in your post.

The angriest part is that the hospital is trying to bury her with the 'there is more to this story then is publicly known' smear campaign. The Hospital just wanted to distance themselves from a loyal worker, so that they didn't have to deal with protecting her.

this story breaks my heart

what is even more upsetting is seeing comments from folks like Shift Lock and Chiach5...according to them, we shouldnt have any doctors or nurses...because if they cant do their job without mistakes, they shouldnt do their jobs period.

the job I work is print related, so when a mistake is made...it's not the end of the world, though it can really mess things up for customers and their events. when I make a mistake, I let my boss know so that we can correct it. I always own my mistakes.

but many times, when my sales rep (my boss) makes a mistake...his first inclincation is to figure out if someone else could have made it, not him...no way. and when its clear as day he made the mistake, you'll never hear him utter "that was my mistake, sorry for accusing you of making the mistake"...because im always blamed first.

I can definitely see how on a much bigger scale, this is far far worse. I imagine in a hospital, the lowest paid employees are the most likely to take the blame for everything...if possible.

which means, folks like Shift Lock and Chiach are helping to create the crappy ass hospitals we end up with...because they dont want the best to stay in place, even if they make one (however big) mistake...nope, they want the ones who are best at deflecting blame and thereby retaining their "perfection" image in place.

I hope both families find lots of healing.

My heart breaks for both the parents and the Ms Hiatt. However, let me send this warning to everyone - if you can NEVER leave a person alone in a hospital. I am a nurse's best friend or worse nightmare. My daughter was hospitalized at the age of 3 for a few days. I never left the hospital. I did all the physical care of her, but questioned everything the nurses were giving her, asking about the dosage and even once prevented a nurse from giving her a dose 3 hours early.

I worked my way through college and graduate school in mental hospitals. I had two patients that had brain damage from medical errors (most of my patients were simply there from biological mental illness or self-medication errors/reactions). I'm a freak about this... but people should be aware. In 2006, a report by Institute for Safe Medication Practices stated that 1.5 million Americans had a medication error in hospitals, nursing homes or doctor offices each year. Most were minor, but enough serious to cause injury or death. It's why we've gone to electronic perscriptions, but there are still errors because humans make mistakes.

I will trust a french hospital, before a hospital in america, the hygienne there is very strick.

lucetmoi- the baby didn't die from lack of proper hygiene practices by the staff. The baby died from human error. I hate to have to break it to you, but the French are just as susceptible to human error as any other nation in the world. As for people not getting sick in French restaurants, why was it reported within the past couple of days that France has found the same strain of E. coli as the one that caused deaths recently in Germany?

A wonderful friend of mine died in a new mexicohospital, because she caught a deadly infection in her leg that she had scratched.

Your wonderful friend probably caught a staph infection when she scratched her leg that had absolutely nothing to do with the hospital. Staph is everywhere, not only in hospitals. A basketball player in California lost his foot as the result of an infection from a cut he received when he was walking barefooted. Certain strains are not affected by antibiotics and there is little that can be done to fight the infection by going to a hospital.

If you want to insult American hospitals, then find something valid. Don't try to create situations that aren't relevant. I would opt for a good, old American hospital any day.

A lesson to be learned here would be to have doses of medications checked by a second nurse or physician before being administered. Hospital staff are frequently overworked and stressed and two people are less likely to both make a mistake if they check each others work.

I know that sounds reasonable, but in practice, it isn't. I retired last year but I was a critical care nurse for over twenty years. I know how hectic & chaotic that environment can become & how very many medications there are to be given in the form of either injections or through intravenous infusions. And how many adjustments have to be made by the nurse based on current readings of the patient's condition (blood pressure, cardiac pressures, etc) & how many of those must be made as quickly as possible much of the time. The other nurses in the unit are just as busy with their patients. It just isn't possible to track down an available nurse to oversee each & every medication adjustment or delivery. It would prevent patients from receiving adequate & timely care in that environment.

Over the years, hospitals have modified & continue to modify methods of labeling & dosing medications & IV infusions so as to eliminate errors as much as possible. Every reported error brings on an in depth investigation & discussion of whether or not something can be changed about that system to prevent said error in the future. They have tried to eliminate nurses having to draw up dosages from larger dosed vials as much as possible by having all ordered dosages delivered to the unit in exact amounts.

But humans are human & errors will happen. It just isn't possible to make the system 100% foolproof & incapable of susceptibility to human error. Especially in the critical care & emergency room as well as the OR, there are just too many times when a medication must be given on a one-time basis based on standing orders in response to changes in the patient's condition. Those medications must be kept on the unit in larger dose vials because the dosages will vary so much based on that change in condition along with the weight of the patient or their response to said medication in the past. And more often than not, they must be administered very quickly.

There are so many readings to be taken & infusions to monitor & adjust in infusion rates & medication dosages along with regular medication administration & changing of infusion bags & complex lives all while also providing basic physical care to the patient & the emotional support of the patient & family -- all by the single RN assigned to that & possibly another patient.

This leaves no time to leave that patient (who may be too critical to permit leaving the room) to double check other nurses' medication delivery & get a nurse to double check your own over & over throughout the shift. It just isn't practical or doable.

Unless you find a way of replacing RN's with robots who can perform all the complex determinations required of a critical care nurse & the physical care & support of the patient & their loved ones, mistakes will happen. Everyone does as much as they can to correct the system to prevent them whenever one occurs, but it just isn't possible to create a system where human error will never happen.

My heart goes out to everyone here. The patients family & the nurse who died along with her family. I can imagine myself in her position all too well & it's a terrifying thought.

Anyone who says they've never made a mistake, especially in a complex, high stress and long hour occupation such as the medical field, is either delusional, a liar, or is on their first day on the job.

In dealing with children their is no margin for error outside of never been done before, theoretical, experimental (all by consent of course). When a parent loses a child it is devastating utterly devastating and asking them to accept that mistakes happen is a tad bit insensitive. 1+3=99 is a mistake, OD'ing a child is a fatal error. Fatal errors and mistakes aren't the same ask any parent.

As far as killing herself, in some cultures they do so for less, but sounds like she had beat herself up enough and probably needed a whole lot more mental help in getting through this.

This woman, who by all accounts was a great nurse, was engrossed in a conversation which distracted her and she made the error, which cost a child it's life. Now whether the conversation was with a coworker or she was talking to the child's parents, she should have stopped the conversation to make sure she was giving the correct medication, at the correct dose, etc.

I have had numerous medical tests, procedures and operations. There have been times when the medical staff were engrossed in conversations, to the point where I felt like an intruder! This does nothing for patient confidence. When a medical professional is at work their focus should be on the patient during a test, procedure, operations and administering medications, not on who's scheduled when or what's happening on their favorite TV show. They need to save the conversations for in between patients or their breaks.

RN, so sorry for the typo. Interesting that you fixate on this detail.

There are situations where you double and triple check the action that is about to be performed.

I know of a situation where my co-worker\manager was having back pains and it was ironic that I would tell him to tough it out instead of going to the hospital for treatment (joking with him). The next day he call in to say he could not deal with the pain and went to get a local corticosteroid injection. That morning was the last time I talked to him, after getting the shot an air bubble was also injected into his spine.

My heart goes out to both...but some jobs are more demanding than others. All professionals including non-first responders have a responsibility that provides little room, if any, for errors. If you don't have the stomach to deal with the consequences...you should not be doing the job to begin with.

If I read this story correctly, the child was already a critically ill heart patient, right? And died 5 days after the incorrect dosage was administered? Suppose the nurse had not said anything about the error...would she have faced any discipline? Or would it have been regarded as an unfortunate and tragic, but unpreventable, loss of a child?

She did choose to do the honorable thing by admitting to her mistake (not by her suicide).

A terrible tragedy and a very sad situation for Nurse Hiatt. Yet, once again, the hypocrisy that is exhibited here is staggering. I have read 20+ post from the blame anyone but the person involved, take no responsibility Liberal crowed whining about the "Poor little nurse with the big bad bosses foot on her neck" being absolved from responsibility because some liberal says she is overworked and under too much stress. Yet if this was some mechanic who had misdiagnosed the fix for one of you liberals car and it cost you a few hundred bucks, you would be ranting about how the auto industry is a NeoCapitalist, non Agrarian, Medieval minded, Satan who assaulted your pocketbooks in the name of the Oil Companies.

Freekin Hypocrites, have you no personal responsibility?

The woman made an error, but before you Loonies go running to her defense lets get honest. I myself have experienced a near disaster in my life concerning a nurse. She was not over stressed nor did she have to much responsibility to cope with at the moment. No, She was running her mouth about her daughters wedding and the color of the flowers to another women who was restocking the Emergency room Draws while she was pulling a syringe full of what amounted to Morphine that a Doctor had requested (I was there with a Kidney Stone Attack)... She handed the needle to the Doctor who had left for a moment and returned when he realize the dosing was nearly 3X the dosage he had requested. Obviously, I'm still here so they fixed the error. Had they not they would have had to administer the anti-Opiate drug Naloxone, which they had no way of knowing I am extremely allergic to. I only learned of my allergy when checked for it before a major surgery 3 years before after a car wreck.

Was this nurse who nearly killed me "EVIL"... No, of course not. Was she stupid or incapable of performing her job? No, she was a very good nurse and I would imagine she still is doing a fine job.

Was she was was distracted with her own nonsense when she should have been concentrating on the job at hand. If you are going to be a Medical Professional, you are entering a field that does not suffer those who "have bad days" or "Need to take it light" for a few hours. Want a job like that? I hear Obama is hiring for the Justice department chasing illegal guns they allowed to be bought with "straw purchases" and turned loose into Mexico on purpose, they are all agenda propitiating, ignorant people led by a Arrogant, Self willed President, so... you'll fit right in.

I hold no ill feelings, But I did say to her that I had been listening and KNEW her mind was elsewhere while she was doing her drug dosing. She disagreed... I'm not a bit surprised. Most people when confronted with their own ineptitude or lack of responsible thinking will deny it. Women and men. Liberals make a living doing it.

I'm very sorry the child died... only Nurse Hiatt knew for certain her depth of responsibility, comitting self murder does not help with her defense.

Yes it is possible to double check drugs with another nurse..... which should be done especially when the names of the drugs are close in spelling especially as often happens with generic drugs.

There should be better staffing in intensive care units..... to 1 to 1. But it is cheaper to employ an RN and then have nursing assistants etc who work under the RN's license instead of employing more RNs. Folks need to realize that many of the people/managers/directors making the decisions regarding staffing haven't been at the bedside in years if ever...... LOL

These hospitals will throw the nurse under the bus in a NY minute.... even if it is the doctor's fault. The doctor prescribes the medications but it is the nurse that administer it after it has been filled by the pharmacist or his/her assistant.

The nurse is required to not only administer the drug but must also know about drugs and dosages more than even the doctors, and have the strength and nerve to question same, as the nurse is working on her own license.

To cut cost the hospital will pink slip nurses first...... and pile on the load on the remaining nurses that are left.

The hospital probably terminated the nurse to decrease the possibility of being sued, and may feel they will not have to pay her her pension or other benefits if they can fire her for cause.

That is why nurses should carry their own malpractice insurance as they can be sued and need to protect and defend themselves. It also helps to be a member of a nursing association and possibly a nurse union..... to help work on the nurse's behalf.

Registered Nurses and other para nurses are not paid enough for the work they are required to do imo.

In the Washington DC area, a nurse who was snowed in and could not make it to work because of the blizzard, was fired after working at the same hospital for more than 25 years and had no absence, attendance or tardiness problems.... Go figure.... LOL

As a former clinician who worked in and directed Neonatal ICU's for over 20 years, and now works with Electronic Medical Records and related medical clinical decision making, I'd like to make the following observations:

1. I have seen this kind of tragedy more than once - from the infant's care point of view, as having made several similar "power of 10" errors (all of except one which were caught by diligent RN's and pharmacists, and fortunately non-toxic, even though I am terribly obsessive compulsive about details), from the parent's point of view by promptly explaining to the best of my ability and how we were going to prevent this in the future, and continually we reconsidered our clinical procedures to make them safer by building redundancy into the system.

2. This is not meant to be "holier than thow", but for those of you who have not been in "our shoes" (meaning critical care medicine and nursing), you have little idea how heavily the thought of an event like weighs on your mind. If you do this long enough, it *will* happen; the question is when.

3. For those of us in pediatrics, there are three factors that always weigh heavily on us.

a. The "physiologic reserve" goes down markedly as the child's/infant's weight goes down - what an adult might tolerate well, might, in the case of a 500 gm premature (1.1 lbs - a little bigger than my hand from head to toes) be much shorter - the "reserve" is measured in seconds not minutes.

b. Pediatric doses are calculated based on weight - therefore must calculated or based on "dosage tables". As a result, there will be, to some degree (hopefully infinitely small, but practically not) some risk of a "power of 10 error - misplacing a decimal point. There are multiple ways to try to "engineer" this out of the system -

1. by Electronic Medical Records, calculators with "dosage apps"

2. triple checks by physician, pharmacy and administering nurse

3. double checks by 2 nurses

4. teams of staff - like in an ED that gets trauma cases where one "records" what happened, one does drugs, etc.

c. This is very different from adults where "1 amp(ule)" af a drug has been premeasured for emergency use. Many of us, for years, have worked on system improvements, well before the Institute of Medicine's 1999 report "To Error is Human" and the follow-up "Crossing the Quality Chasm".

For the clinically inclined - a premature infant with Down Syndrome and potential congenital heart disease (a large hole between all 4 chambers of the heart), suddenly has a cardiac arrest with a last monitor strip that looks like a heart attack (myocardial infarction). Now, within seconds, what are you going to do, and with what? (True case - a venous air bubble went across the "endocardial cushion" defect, lodging in a coronary artery and causing a "heart attack"; the infant was treated within a minute, and lived to have the defect repaired).

4. As economics has "squeezed" the hospitals, the hospitals have "squeezed" the clinical staff "worker bees", as opposed to middle and upper management. I have seen nursing "middle management" throw the "worker bees" "under the bus" more times to "upper management" than I can believe in order to "quash" true clinical improvement they never thought of (we clinicians, as Ms. Hiatt has so sadly has shown us, are our own worst critics, especially after a really bad night "on-call".

5. Electronic Medical Records (EMR) have been touted as what is going to "save" medicine. I have worked with these (down at the database, programing, and clinical decision support level) as I truly think this will improve, to some degree, medical/nursing care. I also believe that the benefits have been grossly "oversold". (Enron anyone?) People far smarter than me have been working on this for almost 40 years (really!, and I for 15) and we all realize that "clinical-grade" decision support (diagnosis confirmation, drug interactions based on computer and hand-entered information is 20-30 years away). Until then, clinicians will use these as "assists" and "checks" because real patients are often much more complex than a child's ear infection (geriatric heart disease/failure, diabetes, chronic lung disease after years of smoking, and high cholesterol).

Think about it...

Utter, that is one of the best posts you have ever made. It seems that there is a lynch mob out for the nurse, the hospital and any neck available.

But, I wonder. What would it feel like to know that I had caused the death of a child in a situation like this? Would I consider suicide? Would there be anything I could do to make things right? If I were a religious person, would there be any hope that my God could forgive me? Would the rest of my damned life be worth living under the circumstances? Would I be in a prison cell after spending my career helping others live?

This whole set of events could not get any uglier.

But it is cheaper to employ an RN and then have nursing assistants etc who work under the RN's license instead of employing more RNs. Folks need to realize that many of the people/managers/directors making the decisions regarding staffing haven't been at the bedside in years if ever...... LOL

In over 20 years working as a critical care RN in probably 30 or more facilities (I often worked extra shifts through an agency because I was raising four children alone thus the number of facilities I worked in besides my full time job), I have never once worked in a hospital that permitted anything but licensed & experienced RN's to care for patients in a critical care unit.

Most of us actually wished they WOULD allow the critical care nurses to have a nurse aide to assist with the mundane chores such as bathing & cleaning up incontinent patients & the like since those are time consuming activities that take away from the RN's time available for the more critical care activities that actually require a licensed RN.

Yes, it might have been harsh to fire her after one mistake in 25 years, but if the hospital did not fire a "fall guy", since there was a possible death involved, they might have been liable in a lawsuit.

(yes, I said "possible death" because, as the article states, the child was critically ill so it was impossible to tell whether the child died due to the OD of calcium or because the child was going to die anyway)

Utter-disbelief, I said if, "gross negligence was not involved." That implies that I realize I don't know the whole story. What I'm saying is that if what is reported is true, and simply a personality conflict was not the true cause of the firing, then she should not have been fired for one mistake.

To have the thought of being responsible for the death of an 8 month old baby on your hands is truly unimaginable, and personally, I doubt I could bear it myself. RIP to both baby and nurse.

Grump in NM -

To answer your questions...

But, I wonder. What would it feel like to know that I had caused the death of a child in a situation like this?

In short, awful beyond belief. Attributed to Sir William Osler, but also Hippocrates primum no nocerum (first, do no harm)

Would I consider suicide?

Yes

Would there be anything I could do to make things right?

It depends on the circumstances you feel in your heart

If I were a religious person, would there be any hope that my God could forgive me?

Yes, we will not be judged here but elsewhere. Those of us in this life, in the health professions, often despair because a truly compassionate God would not subject innocent children to the pain and suffering of life and an early suffering death (observations by someone who has sat at the bedside when one of our patients dies). Being on this earth, at this time, does not reflect "all" time. That is beyond us.

Would the rest of my damned life be worth living under the circumstances?

Damned by who - yourself, hospital administration, the Nursing Board, God?

Would I be in a prison cell after spending my career helping others live?

Possibly - I was.

A true story...

One night, my wife, after a long day driving an elderly neighbor in "Leaf Peeping" season, drove that neighbor home (lives 7 min away). On the way home, she veered off the dirt road into the woods 300 yds from our house. A passing car was told that I, a physician with critical care and trauma experience, lived up the road. Would I assist?

Foolish me said yes, jumped into the car, drove down the road to find it was our car and my wife. Although the local rescue squad was milling about in the road, I ran over to the car ash found my wife staring straight ahead, unresponsive (Glasgow Coma Score 11/15), no one at the car.

Severeal minutes later a part -time deputy sheriff walked over. I identified myself and pointed out that she had an altered mental status and given how far off the road she was, even though it was claimed she was intoxicated, that by all medical criteria (including EMS), that a head injury and spine injury must be ruled out REGARDLESS of whether the victim was intoxicated or not. As a result, I was arrested for "disorderly conduct" and later "resisting arrest" and jailed overnight. My wife was also jailed passed an alcohol breath test, and noted to have a "lump" over her eye.

After release, she was examined x2, had head CT and neck CT (which should have been immediately), and had clear physical findings over the next 5 days that her forehead hit the steering wheel as the air-bag did not deploy. She was post-concussive for 6 months.

$14,000 later, I pled "no contest" to the disorderly conduct charge as it would have been $14,000 more to take it to trial. I notified the Medical Board prior to my license renewal that was granted in 2 days without further discussion or inquiry. No one at the State Medical Assoc has EVER heard of a healthcare arre-ted for voluntarily rendering emergency healthcare.

Moral: Would I do it again if I knew the potential consequences?

Answer: Yes, because there was no other ethical choice, despite I now have a criminal conviction as I pleaded "nolo" and was jailed (one of the longest nights of my life...)

For those of you who do not work in healthcare, this might seem terribly, terribly foolish. For those of you who do, this was the LAST thing I thought that Good Samaritan care would lead to - it's what we do - care for others.

Chiach5 is right. People who work in the medical business are very well paid for their "services." Don't we know it when we get the bill. The last time I went to a clinic for tests, I spent over an hour-and-a-half in the waiting room past my appointment time (even though I made it weeks before and right when the medical business opened), and finally saw the doctor for twenty minutes who poked me and said "does this hurt?" and when I said no, he stated in his expertise "well, I don't know what's wrong with you." So he scheduled me for "tests" which meant taking my blood and pee. I had to wait two hours to do that, and when it did, that lasted for a whole five minutes. I had to wait four weeks for the "results" (and whatever was wrong with me had long since stopped) which all came out "inconclusive"and after that I got a bill for close to $3,000.

Medical people are over-well paid for what they do (and what they don't do, or are suppose to do but don't do it). This women was an RN, and obviously was not hurting financially. It was revealed that she was "distracted" by carrying on a conversation with somebody else when she was being over-paid to do her job. When I have to go into debt to pay for medical "services" (because insurance no longer covers everything, if it covers anything at all), I expect total attention given to me for what I'm paying for. There is no room for error, not at those prices.

I'm sorry this woman is dead, that her career was "ruined," but she didn't do the job she was well-paid to do. She was fully responsible for the death of the infant because she didn't do her job. It would be interesting to see what she was paid. If she made minimum wage, well then, no one should expect anything more than what minimum wage pays. If she made $40 an hour, then she had the obligation to give that level of service. She didn't.

lucetmoi.........>>>>This has absolutely nothing to do with hygene. What good would a beta shower have done for that baby? Next time, read the article.

Jerry....>What she was paid has nothing to do with it.

@Brenda I thought I understood your post. I am not sure why the need to clarify for me.

@grump - Thank you. I will make a confession, when I first got my license, my number 1 prayer was "Please God, don't let my first critical call be a kid." As we know God has an interesting sense of humor and my first call was for the unresponsive 3 year old. I get there and her hysterical mother greets me at her apartment and hands me her lifeless 3 year old. She is yelling at me in spanish I barely understand and partner is asking what happened all the while the baby is limp, lips blue, unresponsive to any stimuli barely has a pulse. I lay her on the floor and postioned her for rescue breathing and the air would not go in. I repositioned her head and still no chest rise. I look in her mouth and I can barely make out something colorful lodged in her throat. At the time you were not allowed to do a finger sweep of a child's mouth but there was that damn object! I knew my boney fingers could get it out and I broke protocol and stuck my fingers in the kid's mouth and got that damn (jax) ball out of there. I gave her 2 rescue breaths from the bvm and she sputtered coughed opened her eyes, looked at me and started screaming bloody murder. It was the best sound I'd ever heard in my life. To this day my heart still races when I think how I could have lodged the ball further in her throat if I'd misjudged the dexterity of my fingers and it makes my blood run cold. It sits on my chest and I try to just remember there is a now high school kid out there because I got lucky. I don't recommend my actions to anyone because I feel guilty even though I didn't hurt her. If I had killed her I know I'd be dead too. I will have to double check but I believe ER Doctors had/have the highest suicide of any profession (cops may hold that title now) but it's not easy baring witness to the mortality of others and by default your own everyday and when you are the one slated to help and you can't or make an error under the pressure it's one of the heaviest burdens to bear. Please know that none of us want errors and that good medical professionals welcome the checks and balances but some safety measures can actually cause deaths too. I lost my loved one due in part to an MD's poor judgment. I am shattered and don't really even want to be put back together but I know that errors happen and no amount of retribution will change the past. Examine if the medical professional's lives saved far exceeds the lives lost and couple it with his general demeanor towards the lives of others then make a wise decision. Please feel free to organize a lynch mob for me first because I broke protocol too.

Utter -

As we know God has an interesting sense of humor and my first call was for the unresponsive 3 year old.

Don't we all know ; - )

Jerry -

I understand your rage - I'd be ripsh*t too.

But here's the problem...

When I (and some us older f@rts) started in medicine, it was personal. Starting in the late 1980's - 1990's "managed care" started to make it "impersonal". The whole idea was to make medicine a commodity - like getting your oil changed - the lowest "bidder" was now on your Insurance Co's "panel". Therefore, any personal relationship you had with your doctor was "engineered" out of the "system".

The next step was "vertical integration" - doctor's solo or small practices bought out by hospitals so they had a "locked-in" source of patients. Unfortunately for patients because of economic "incentives" as employees (not as independent practitioners) patients were/are "steered" within the "vertical organization" as opposed where clinical judgment would send them.

Result - what you experienced (probably). Practitioners paid on "incentive" for maximal number of visits in a day, maybe amount of lab and radiology tests ordered, office staff that are totally clueless, and "charges" that are not only the practitioner's "real" charges, but the healthcare system's "overhead" (AKA - surcharge, profit, etc.). What you will billed is far different from what the provider was actually paid.

I'm sorry you feel this way about nurses. Most of us went into this field to care for others. We studied very hard, sacrificed alot of time, worked our butts off, worked weekends, holidays, nights, up to 14 hour shifts, many times with NO lunch, not even a BATHROOM break all because we were so busy being "overpaid". If I had to take a wild guess I would say most of the critics of nurses and doctors out there would never have the guts or heart to do what we do and you will never understand how we feel. So until you have walked a mile in our shoes, please don't judge us.

Every time that I had a transfusion of any type, 2 nurses were present. They verified the name, the med, and the dosage---both of them. This is a highly experienced nurse, probably has done this thousands of times. This is a dosage mistake. From the drugstores to the hospitals, it happens. I'm thinking---how many hours had this lady worked. Was she fatigued? Did she forget her glasses? An adult probably could have handled the dose? It's calcium, a mineral. It's tragic, but it's over. The article talks about acknowledged mistakes. What we know about. It's those that get kicked under the carpet that we need to be concerned with.

Ok, I will play the devils advocate here:

Many of you are saying that "to err is human" and that they came down on her too harshly. Yet, fail to consider that many professions will take your license away over an "error." Same thing as firing them since they can not work in that profession again and it isn't required that you accidentally kill or maim someone.

A CPA screws up on a Tax form and can go to jail (depending on the screw up); A lawyer screws up a case and can lose his license or have his reputation smeared as "incompetent;" An engineer screws up the math and a structure collapses - even if no one is killed or hurt, he will lose his license.

All of this is malpractice and anyone in these fields can be sued for an error.

If an ordinary citizen screwed up and killed someone they can go to jail for involuntary manslaughter.

Why do we want to let our medical professionals off the hook, but hold other professions to a higher standard?

I dont believe your statement of no bathroom break. That statement was a little overboard. Your emotions probably let that one 'slip'. Most of us as patients believe that the vast majority of nurses are well educated, qualified and caring individuals. This is a very sad story and I feel for the patient's family as well as the nurse's. Human error will always occur. In certain careers like the medical profession or the aviation industry, (I lost my career here and honestly did contiplate suicide. I also have a difficult time coping with the loss but this is not about me.), to 'target' someone who has made a rare error is not an answer. A written reprimand should be the strongest action against someone who has made a genuine and rare mistake and then a review should be performed and maybe additional training or supervised work may be required. Direct finger-pointing is not appropriate in these professions.

Aviation practices several checks and re-checks of repairs and operations for safety. I am sure the medical profession is the same. If an error were to occur, it is the proceedure that should be critiqued. Proper recording and verification should be employed. if a medical provider continues making poor judgement then action should be taken against that individual. As I mentioned before, there are certain occupations staffed by individuals who love what they do as I did in aviation. Medical professionals are the same. To error is taken very personally and the guilt and feeling of 'let down' can be enough punishment which will lead to determination that the same errror will not be repeated by the one who caused the accident.

Amen!! We study, sacrifice, scratch, scream and crawl all the way thru nursing school to help other people in their sickest and darkest hours (not to mention dealing with the stressed out family of the patient). So before you criticize nurses for what you think they are or are not doing, ask yourself...Could I place other people's lives in my hands on a daily basis? If the answer is NO, SHUT UP!! If the answer is yes, go to nursing school...then judge us!!

I lost a parent to a medical mistake. I think this baby's family was much more forgiving than I could be. I understand how easily it happens, but that doesn't ease the pain for the family that loses their loved one. I myself have multiple drug allergies and I am terrified of becoming sick where I cannot speak for myself. I can't tell you how many times I have been given a prescription and come home and look it up and the physician has prescribed something in the same class that has caused an allergy. No harm done when I catch it, but imagine not being able to double check.

Blondeness re 1.35 - I completely agree. The nurse said she was talking when she was supposed to be administering medicine.

I'm not only tired of chatty kathy's in the doctor's office, I'm tired of chatty kathy's everywhere.

Customer service is the most important aspect of most people's jobs.

Not to mention, the hospital was emphatic that they don't fire people over 1 mistake.

And I don't know about you but if a co-worker kissed me on the cheek - male or female - which this nurse did - I would consider it harrassment and totally inappropriate.

I am sorry that she felt no way out but to kill herself.

Karen is on the right track here...

And I will add this: The corporation probably is more worried about the effect this report may have on stock prices than either the patient or the caregiver.

As long as we live in the "it's all about me" world now so praised among many, this is what will unfortunately continue to happen to someone else......

Good job Karen from LA

Routinely , I get B-12 shots and iron transfusions. When I arrive, I pick up the script and take it to the lab for filling. The "med passer" will verify that what she fills is what was prescribed. Another nurse will pick it up and it's verified a second time. Before it's IV'ed into me, 2 more nurses verify that the bag is once again what I'm supposed to get. That's 4 different sets of eyes that see that bag and verify that it is what I'm supposed to get. I'll add this. As a retired commercial driver, we're taught that all accidents have causes and 80% of the time it's human error. It's somebody not doing what they should be or somebody doing what they shouldn't. Apparently, this nurse took the calcium directly to the child with no one else in between. That wouldn't happen where I go and shouldn't have happened here. The tragedy here is the child and a 25 year veteran nurse died over this event.

qudrcps---I thought there's a Good Samaritan law, to protect people who attempt reasonable actions to help save a life but aren't successful.

halseyjr----the bathroom breaks stories are true.

I have to reply to all the people who say, none of us is perfect..... The medical community HAS hold themselves up to a higher standard and have a zero tolerance on any situation that results in an injury or death! NO ONE should ever have to accept inferior care for themselves or their family.

If your interior designer orders the wrong kitchen cabinet and it puts your project back a month or your mechanic forgets something and your engine blows up, those are errors that can be eventually corrected...... you can't correct dead!

Nurse was drawing my blood and asked that I confirm the seal was actually unbroken on the cap. I said "well it is actually broken, please use another one" she got all prissy and said that the seal had broken by "accident" when she twisted it slightly and not to worry about it... I asked her again -politely- to use another one. She complied but was a total bitch about it.

It was a very uncomfortable blood draw after that!

Bubbacat -

I thought there's a Good Samaritan law, to protect people who attempt reasonable actions to help save a life but aren't successful. (1.67)

You are absolutely correct - there is a Good Samaritan law in every state to prevent CIVIL suits in cases where a physician, nurse, EMT performs to the best of their ability (in other words, an adult orthopedist does the best they know how - like back in medical school - to take care of an injured newborn). Under those circumstances, acting in "good faith" the provider cannot be sued in case of an "adverse outcome".

There are often exclusions were someone can be sued - gross negligence, this occurring in the hospital instead of the "real world", etc.

The purpose is to encourage providers to stop at an accident without fear of being sued, instead of driving on and "ignoring it" - many do as there is an ethical obligation to do so, but not a legal one.

In 2 states this is not voluntary - Vermont & Minnesota DO require providers to stop - failing to do so can result in a CRIMINAL misdemeanor.

My case in 1.50 was a CRIMINAL not a CIVIL case.

Question - Ask me if I would ever stop again?

Answer - The day after my hearing, I was driving on the local Interstate in 15 degree weather and it was snowing. A car had overturned in the median, there was blood on the snow as the victim had somehow had crawled out through a window - his English was marginal (here legally as a refugee). I stopped and did what I could to keep him warm, keep his arm from bleeding out, and keep his neck in line until the EMT service showed up 15-20 min after someone had called 911 immediately.

Jerry @ 1.51 You seem to be really hung up on what she was paid. I assume from that that you are not (Let me guess- does your job involve the phrase: "Do you want fries with that?" on a regular basis?). And since you feel that reasonable pay equates to perfection, can I assume from your income you are a screw up?

And by the way, next time someone gets food poisoning from one of your burgers, I'll be joining the mob hollering to throw your sorry carcass in jail.

USAF Vet @ 1.5

I assume being in the military you're familiar with the terms "friendly fire" and "collateral damage"? Are you advocating that we imprison our own soldiers for these mistakes?

And if you're advocating revoking licenses for any mistake and imprisonment for ones involving death I would hope you are a very patient person because there will be about 6 health care providers left in the country in fairly short order and it might be a couple of weeks before the doctor can get around to looking at that artery you severed when you were out chopping wood.

And in every case you've cited, people MIGHT lose their licenses IF it's shown that the person was grossly negligent or had a history of problems or did something dishonest or illegal. None of the cases you cited would actually result in automatic license revocation. And it's the same in medicine.

I've had one person work for me who claimed she had never made a mistake. I got rid of her as soon as practically possible since she was either dishonest or clueless.

I will trust a french hospital, before a hospital in america, the hygienne there is very strick

This from a person who prefers the medical establishment that killed Arafat. The only treatment that would have given him a chance at survival was refused to be performed by French doctors because it was both too expensive and too American. I believe the term that was given it was "cowboy medicine."

Of course, I am sure that a good portion of the world see the French medical system as doing Israel and the world a favor, but, still, it was the French medical system that killed Arafat.

And, that bit about showering with betadine before going in for a procedure? When you consider that bacteria multiply every 20 minutes on a warm body, do the math and see if that is not a waste of time before the person actually gets there for the procedure.

French medicine...so primitive by today's standards in many respects (but not all; their cadaver donor unit and research with cadaver body parts is almost second to none). But, that is what people get with socialized medicine--primitive procedures overall, refusal to use radical procedures even if they are the only thing left to save your life, and waiting periods for major procedures when often the clock is ticking.

Thank you Dr. Bill...I have noticed in my profession that people MUST be perfect also and nobody is perfect. In my profession there are sometimes serious consequences for errors. Very fortunately peoples' lives are not at risk if somebody makes a mistake.

Yes, Dr. Bill..we have forgotten we are human since our employers (the hospitals) are even more scared of a lawsuit than of loosing the best of their staff.

The first thing we need to do is reform all those frivolous lawsuits.

I remember reading about this when it first happened. I guess there was a big deal about the staff trying to cover up the mistake by marking the bag with a different number over the actual dosage.

I feel really badly for this woman, 25 years of service and one mistake means termination. I understand that it lead to a death but there are many people in the medical world who die because of mistakes and this child was, apparently, exceptionally fragile already.

Agreed Ram -- suing over every trivial thing has become a way of life in this country. A few years ago, I dropped something on my foot and broke my big toe. No at fault but me. When it was healing the nail came off. Looked dreadful, but I figured it wasn't that big a deal -- it would grow back.

The poor doctor treating me acted like he was almost afraid to tell me it might not. Oh well, in the grand scheme of things, it's just a toenail. Later, the PA said he'd been sued for something very similar. I cannot imagine how the poor man could have been held responsible for something like that, but apparently he was.

Totally ridiculous.

BTW, it did grow back!

Dr. Bill, you have just zeroed in on an enormous problem with our society and a costly one. You have echoed a report I just heard on NPR about emotional illness on a global scale.

The U.S. is the most anxious country in the world. We are beset by illness of our own making and we consume vastly more drugs than any other country.

We are not allowed to be humans liable to error, fatigue, or even illness. Moreover, we must be militantly self-reliant and individualistic. Need is not allowed. We pay for all this detachment from reality in suffering, loss of productivity, medical expenses, crime, and death.

I believe these delusions are the crux of the division in America today. Listen to the Palins, the Christies, the Bachmanns and their ilk. The real message is we should not seek an accepting, cohesive, mutually supportive society. We must vigilantly uphold the myth of "rugged individualism". Not that any of that sort actually live what they preach.

Toss in the religious fundamentalist and their smug self-righteousness and it gets worse. My God (not blasphemy) people are killing their children because they refuse to accept they have curable illnesses e.g. Dale and Leilani Neumann in WI. Their poor child suffered and died a terrible death because her mother was certain the child had sinned. They refused to get her medical care because the answer was prayer not medication. She died of diabetes.

If we are to survive to say nothing of living full, joy-filled, productive lives we must accept the reality that neither we nor the world can be perfect.

There are a few problems unique to this case. The nurse had given care to this baby before. So she was very familiar with this baby. If she had given the same medication before this is even more problematic because she should have noticed the dosage difference. She admitted she was talking while getting the medication ready.

Very, very sad for all.

jkatze: You have deliberately misrepresented the views of conservatives and religious people for the sake of your own ideology and philosophy. Perhaps you should look to yourself and others like you for the causes of divisiveness and stress in this country.

A profoundly spot on comment. It seems the collective reflex of our society is to judge one another based on the consequence of a mistake rather than the mistake itself. For example, if this poor nurse had accidentally administered a wrong dose that for whatever reason, even if only by the grace of God, did no significant harm, she'd still be alive today and working in her chosen career.

Increasingly, it's becoming human nature to crucify the fellow victims of human tragedy, even though at it's very core, that's faulty reasoning. There was a time, for example, when if a toddler drowned in a pool, the most common public reaction would be "Those poor parents." Now it's more likely to be, "Where were the parents?"

We don't believe in mistakes, but we do believe in lawsuits. And vengeance. And that is what is sad.

jkatze, your comment is yet another reminder that the biggest obstacle to overcoming division is assuming you bear no responsibility for it.

If she was a bank executive she would have gotten a promotion, a billion $ bonus and would be on vacation on her own private island with a couple close congressional friends.

Charles Smith-438222,
Ther Sarah Palinses and Michele Bachmans of this world besmirch the once-good name of conservatives. Perhaps you should look to them and others like them and Ruch Limbaugh, etc. for the causes of divisiveness and stress in this country.

Dr. Bill,

If I could Fan and Fave you I would. Excellent post.

This is the end result of the winner take all society we seem to live in. No room for mistakes, and no second chance, unless you are a celebrity boozer or skirt chaser. This is a sad story.

Jkatze,

You should be ashamed for bringing politics into this. You should learn to keep your derangement syndrome in check.

This is about, from all reports, a dedicated and caring nurse who made an error. I will pray for her tonight, but YOU are on your own.

@jkatze

It's good you realize that humans are not perfect, it is a shame you feel you have to blame someone to have reached that knowledge.

Blame. The opposite of your realization.

Jujubefruit--Are you making any point at all? Having been the subject of at least one significant medical mistake, my confidence in the medical profession is a bit jaded at best. There is no doubt in my mind that medical mistakes are made and covered up regularly. In this case, it sounds like the hospital was undoubtedly afraid of lawsuits and a bad reputation, which, ironically, they still might have been subject to, regardless of the nurse's dismissal. Very sad that this turned out to be a double tragedy.

@Dr. Bill;

Kudos to you for this post, and to the majority of commenters who really do seem to get it.

A special kudos to the family of this poor little girl. To say this family handled this tragedy with honor and compassion is a vast understatement. We need more people like this in the world.

@jujubefruit

On the other hand, we need far less idiots like YOU in the world.

Perhaps you're too deluded to understand it, but unless your mother birthed you in a gutter (entirely possible) you owe medical science and those who practice it a debt of gratitude. I personally owe it my LIFE, as do many, many people. Dare I say "most' people.

As a scientist in this field, all I can say to your "playing god" comment is this: Doctors play 'god' because your 'god' is chronically late to the office.

Once he/she/it/they actually shows up and cure malaria, small pox, cancer, heart disease, etc., we'll gladly step down from the healing podium. Until then, we're your best bet.

jujube, looking at your posts I wouldn't think that you were such a religious nutjob. In fact your previous posts are some of the more reasonable I've seen on these forums! Did someone hack your account? Or just temporary insanity?

Dr.Bill's right. We make mistakes pure and simple. We fix it when we can, but many times the "procedures" to correct mistakes are simply uneconomical to the profitability of the business and affordability of the customers. Sometimes we just have to accept that we make mistakes and go on with our lives. Shame our culture doesn't seem to accept this. Sure, you shouldn't WANT to have people make mistakes, but assuming we are error free is simply asinine.

medical professional uses science to prolong the will of man...(et al)

What an idiot post. At least from what I can make of its garbled wording. It sounds like it's coming from the keyboard of a drunken evangelical.

I agree--this woman's death by suicide, as well as the child's, was preventable. If only we had people in teams at all times when dispensing medication, something like this could be prevented--and I'm not saying that it would prevent all incidences, either.

I'm horrified that not only was an innocent 8 month-old a victim of a human mistake, but that it was compounded by the death of a nurse that, otherwise, had a blemish-free career.

Truly sad.

Politics and religion should not be dragged into this. Not all conservatives are cruel nutjobs just like not all democrats are whiny 5 year olds. Not all religious people are bigoted extremists lacking a brain. And not all non religious people are heartless narcisists. Two tragedies occured here and we can learn from both of them no matter what our opinions are. 1. no matter how long you have been a nurse, treat a medication administration as if it is your first time to give it and double check yourself 2. people make mistakes and many times we are our own worst punishment. consider grief counseling and an assessment of a broken process instead of firing someone.

Perhaps prefilled dosages and better labeling with larger print and syringe markings would have helped.

You would still have problems, not to mention dosing amounts especially in premature babies and children are based on wieght alot of the time so you would have to make thousands of these preffilled dosages to accomodate and drive up costs.

After similar incidents across the country over the past decade (i.e. Dennis Quaid's kid) more and more children's hospitals are have pre-dossed syringes color coded by age or weight

Of course there's still the mistake of grabbing/dispensing the wrong syringe, and mixing orders between patients. Healthcare is too complex to not expect errors, and the tragedies are truly tragic when they happen. However, hospitals and clinics are full of fail-safes that catch mistakes more times than not. Things are going to slip by once in a while, and it's usually in a way that wasnt anticipated.

Also, pre-dosage is expensive. Unused meds expire. ALl of those syringes, meds, and work to fill are lost. Another reason why healthcare costs are astronomical. Paying for the waste.

Don't forget that some doctors have handwriting that is illegible. A number of mistakes have been made in the past because of that. I know that most hospitals do have some form of double checking the dosage listed, but sometimes things are done in a rush and not properly checked.

Some...have handwriting that is illegible? I personally give nurses, pharmacists, and anyone else who has to decipher the chicken scracthing of the majority of doctors a LOT of credit that they get it right as often as they do!

Don't forget that some doctors have handwriting that is illegible. A number of mistakes have been made in the past because of that. I know that most hospitals do have some form of double checking the dosage listed, but sometimes things are done in a rush and not properly checked.

Funny in a way, but true. Never quite understood the connection there, but it's practically universal. I cannot read my own handwriting half the time (literally) so I type virtually everything. I have noticed that doctors are using digital means of filling scripts in offices, so perhaps we'll catch up to the 21st century soon.

We need a way to make a bright line between mistakes and negligence. This person seems indeed to have made a mistake. Others would hide behind the line and be instead negligent. There is a very bright line here, but it demands health care professionals step up as well when the line is breached.

(example of negligence being the faulty design of CT machines and technicians not checking wedges - called a mistake and clearly not)

Perhaps prefilled dosages and better labeling with larger print and syringe markings would have helped.

That is done in every possible instance. But it isn't possible for all medications because many are given based on a single change in the patients condition/readouts & based both on those readings & the patients weight & age. And they need to be given right then. No time to send an order to the pharmacy & wait for them to fill it & send it to the critical care unit. So certain medications must be kept on the unit in generic dosages so that the necessary amount can be drawn up by the nurse & administered at the time it's needed based on changes in the patients condition. For some of these medications, delay could also have as dire an impact on the patient as an incorrect dose. And then, of course, pharmacies make their fair share of mistakes as well. There's no way to avoid the possibility of human error.

Contrary to what many people here who have no personal experience working in these arenas think, hospitals & their staffs DO want the best outcomes for their patients & make every effort possible to ensure that it happens including constantly making changes to avoid human error.

While it's fine to stay with a patient & observe their care, hovering & questioning every single thing the nurse does is likely to have just the opposite effect than intended. It's like to end up making the nurse so nervous that she makes a mistake she wouldn't otherwise have made.

People need to realize that while mistakes certainly do happen, they are made in an extremely tiny percentage of the instances in which a nurse administers a medication or IV fluid or makes an adjustment in either. The doctors & nurses actually DO know more about what they need to do than does a lay person.

@creature girl

Human nature, being what it is, tells us all that some percentage of people (and therefore doctors and nurses) are arrogant and believe rules are for others, and some percentage are sloppy. Both would be negligent and not mistaken.

As for a patient advocate - as annoying as it is, they do catch mistakes and prevent them.

Human nature, being what it is, tells us all that some percentage of people (and therefore doctors and nurses) are arrogant and believe rules are for others, and some percentage are sloppy.

As is the case with humans as a whole regardless of the profession. In my personal experience, it is a whole lot less the case in the group of medical professionals actually on the front line of treating & caring for patients. More likely to be found among those in the rarefied air of surgeons who have little contact with patients when they're not unconscious. But even then, not often the case. As far as those who have chosen direct patient care, especially in the highly demanding areas such as critical care, there is probably a much smaller percentage of such individuals than in human beings as a whole.

So I'm not sure what your point is.

Hey, HadEnough, with some doctors, it took 3, 4, of us working together to figure out just what the heck the order was. I am proud to say, I believe we had 100% success record on that.

And far too often, bitter patients label the "medical people" as if they are some uniform conglomerate, not individual human beings with individual thoughts, emotions, motives and life experiences.

This was such a tragedy, however, I sure wouldn't have wanted this woman touching a child of mine

Then why let any medical person touch your child. Anyone can make a mistake --- ANYONE -- and my guess is every nurse has made or will make at least 1 mistake of some magnitude during the career.

I've always listened to my pts & do care. Uncaring people usually do not go into the health professions or they leave shortly. ( Unfortunately, there will a very few that stick around, for God knows what reason ). People will make mistakes. Even you, unless you consider above & beyond ordinary human limitations. I very seldom get personally pi~~+& off by someone's posting, but you went too far. Yes, you should report side effects, but every drug will have side effects, which may effect some people to varying degrees, but not bother some people at all. If the side effects are too severe, there's usually another drug to try. Sometimes, you'll have to live w/ some side effects, if they're not too severe & the medicine is adequately treating the disease in question. And saddened is right, there're people that treat all medical professions as one big group, not as individuals.

But back to main thread; a caring, competent nurse felt driven to suicide by a medication error. This is also a great tragedy. She's surely helped innumerable people over a quarter century work, but she'll never help anyone again. She made a mistake. A big one, to be sure. But every human being that exists or has existed had made errors. If only she could've talked to people, other people that cared about her & understood what she was going through, she might still be around to help more people. The health professions are a calling; it is in a sense a great privilege to be able to help so many people in our capacity.

R.I.P. Kim.

Most sincerely,

Bubbacat

I sure wouldn't have wanted this woman touching a child of mine after making such a horrific mistake.

Had the hospital let her stay on - I would say she would probably be the BEST choice for a sick child. A "horrific mistake" is operating while drunk or on drugs, etc - this woman misread a label by one decimal point. Most Americans don't even know the metric system - this nurse was honest and upset. Despite giving the wrong dose of calcium - there are ways to combat that overdose - as the article stated - it is not for certain that this mistake caused the death of the baby - that said, had this nurse been able to stay at the hospital - she would no doubt double check all of her injections, etc - and monitor new nurses, if I had a sick baby, I would want her. Unfortunately, she was humiliated in front of her colleagues and denied her career which she was obviously devoted too. We all have had some doctors whom we didn't like or medications that did us harm. Medicine is not infallible.

My sympathy goes out to the parents who lost their baby (maybe, maybe NOT the fault of this nurse) and it goes out equally to Kim's partner and their children.

...this woman misread a label by one decimal point.

She didn't misread a label, she miscalculated in her head when converting from milligrams to grams. Medical professionals must know the metric system in order to do their jobs, so the fact that most Americans are oblivious to it is irrelevant. Would you use the fact that most Americans don't know how to perform an appendectomy as an excuse for a surgeon making a major error while performing routine surgery?

She's shouldn't have to have been calculating the dosage in the first place. These medications can have dangerous consequences. The pharmacy should be drawing these up, clearly labeling them and they needed to be checked by 2 RN's prior to administration.

You CANNOT judge the entire medical community simply because your experience was a bad one. I have been a nurse for 10 years. Am I the best nurse out there? Absolutely not. I am human. I have good days where everything is fine and then there are bad days where my car has messed up, I've gotten bad news, or I'm just not feeling good. As a professional, you try your absolute best to not bring it to work. At the same time, we are expected to take the abuse meeted out by patients and their families. Stop and think about your behavior towards the professional. How are you adding to the difficulties of their job.

In an intensive care unit, we take care of 1-2 patients that are critically ill. This doesn't mean we sit on our bottoms all night and just watch the patients. We are constantly at the bedside watching fluid levels and vital signs. We have to give medicine every 30 minutes to an hour, we have patients that are literally hovering between life and death. On a regular medical floor, the nurses have between 5 and 9 patients a piece. They have medicines to give, assessments to do, and if they don't have a nursing assistant, they have to do baths, assist with elimination, get water and snacks if the patient wants that, as well. Now, add to this the administration of very dangerous medicines. Our job is so much harder than you could ever imagine.

Does there need to be better packaging for these dangerous medications, absolutely. There also needs to be a better nurse to patient ratio in the critical/accident prone areas. The last thing there needs to be, though, is more legislation that ties the hands of nurses to do their jobs. The job of nurse is done by a human, and unfortunately, that means there will be human error.

As someown who watched my premature daughter receive THE FINEST care I've even seen, I couldn't disagree more. The vast majority of medical professionals DO care, but they're too hurried and harried to display it. You take that for lack of concern, instead of a lack of TIME.

CNOR, that would be utterly impossible. For one, pharmacists aren't doctors or nurses. Secondly, making up thousands of minute, discreet dosages, for the patients would so ridiculously inefficient and impractical it's hard to describe.

@MaximumBob, You hit the nail on the head!! As a nurse for 27 years, and now in a management position, I see this first-hand. Nurses DO care and want to take the time needed to do their job. However, they're constantly pushed to go faster and faster....THAT'S the reason for errors!!

Thought you may want to have a look at the job description of a pharmacist working in a hospital.

Hospital Pharmacist Job Description

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Hospital pharmacists are required to work in a hospital pharmacy, dispensing medicine as per hospital regulations and doctor prescriptions.

Read more: Hospital Pharmacist Job Description | eHow.com #ixzz1QViAnsda

Quality and Standard of Drugs

• The pharmacist has to ensure that the medications are all given under sterile conditions and that the storage is as per drug container specifications. The medication must be checked to ensure the proper dosage is being provided and that the form is appropriate as well (e.g., cream, tablet, inhaler).

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The pharmacist has to ensure that the medications are all given under sterile conditions and that the storage is as per drug container specifications. The medication must be checked to ensure the proper dosage is being provided and that the form is appropriate as well (e.g., cream, tablet, inhaler).

Kmcguire - pharmacists do all of that. They provide the medications that are specified by physician to the nurses. However, pharmacists are not responsible for administering the medications to patients. That is the job of the nurses.

Pharmacists are full doctors, with diplomas, additional schooling, and a doctrate. They aren't medical doctors, but they are "Doctors of Pharmacy."

Pharmacists are full doctors, with diplomas, additional schooling, and a doctrate. They aren't medical doctors, but they are "Doctors of Pharmacy."

Don't know who told you that, but it's far from true. While some pharmacists have a PharmD, most have only 4 years of sciences with 2 years of additional schooling. They are NOT doctors.

Eric - PharmDs are people who have spent a minimum of two years as a college undergraduate and four years in training as a pharmacist. They are not full medical doctors any more than someone who is a Doctor of Philosophy (Ph.D.) is a full medical doctor. Also, pharmacists who are trained as PharmDs are not addressed as "doctor". They are doctors only in the sense that that is the title of their degree. You can search any university medical school website to learn about the courses and training that medical students undergo as opposed to pharmacy students.

Far too often medical people don't listen and don't care.

You don't know what you're talking about. Same with others who think doctors are only doctors for big bucks. It's damned hard work being a doctor OR a nurse & horrible hours. Working conditions suck & the pay isn't enough to make up for them.

Most doctors aren't making anywhere near the money lay people assume they're making. Only certain areas of medicine pay the really big bucks & those aren't generally the ones where they're on call at all hours & working their butts off.

People go in medicine as doctors & nurses because they want to help people. Because they CARE about people. Where the problem comes in is in the limitations put on their time, the requirements that they see so many patients per hour (contrary to popular opinion, doctors don't run the clinics; they have bosses who AREN'T doctors telling them what to do as far as time management). When they are forced to only spend 15 minutes with a patient (including time charting...documenting the visit, findings & orders), they end up learning to turn off or not follow up on things a patient starts to say that aren't obviously related to the reason for the visit. Not because they don't care or don't want to listen but because everyone wants to cut costs & the public doesn't want to spend what it would require for a doctor or nurse to spend an unlimited amount of time listening to everything they have to say during a visit or examination, etc.

And you have no idea how rotten it makes them feel to be forced to spend less than the needed amount of time with each patient. They have no choice. They would be fired if they only saw one or two patients an hour & while that might be fine for those one or two patients they saw, it means they won't be available for the next patients to come in the door. And that's not going to help anyone.

I'm sure there are a few people who go into medicine who don't really care about people but want to make a lot of money, but they are a small minority & unlikely to select a specialty that requires them to see patients on a regular basis such as working in clinic or a hospital other than in the operating room where the patient is unconscious.

"This was such a tragedy, however, I sure wouldn't have wanted this woman touching a child of mine after making such a horrific mistake. Every person in the medical community has to be held accountable for their actions. Too many bad medical personnel get by with things, including not listening to their patients when the patient tells them he/she or experiencing side effects from their medications. It happened to me, and I almost died before switching doctors. Far too often medical people don't listen and don't care."

1. What someone mentioned is true- she probably would have been the BEST option after that because she would be triple checking everything. However, who could blame a parent for requesting a different nurse after that? It would be hard not to even though it was pure accident.

2. Accountability is key- BUT consider how accountable she held herself after that. YOU should try living with that on your shoulders. I bet anything, even jail, would not be as bad as the mental and emotional hell you endure after something like that.

3. Yes sometimes medical professionals do not "listen" to the patient. It is hard to determine sometimes which patients are good historians. Sometimes a patient will say "I took that a couple hours ago" when in reality it was more than 24hrs before. Yes- a nurse should always investigate when a patient asks or points something out but at times that line gets fuzzy. It is hard to understand if you have never been on that side. Also, no where in there did the patient's family question it so just make sure you are clear she was not guilty of ignoring a patient or family member's concerns.

4. every field has bad apples who need to be taken out of their job. she was not one of them. it makes me upset when people generalize about any profession- teachers, phone support, banks, wait people, CEOs. People in general want to do a good job. In the medical field unless you are one of the bad apples, you go into it to care for people. it is certainly not for the money (which is ok), glamor (wiping butt), or perks (skipping lunch).

First, what a shame, she felt responsible, what a tragedy. Both sides.

saddened, Haggi was speaking about THEIR real life experiences and opinion. Not all health-care providers. Haggi said "I almost died, BEFORE I SWITCHED DOCTORS" Your reaction proves that encountering YOU, that you may perfectly fit his description. Who is really the bitter one? Huh? Read you message again...

ABCzyx, there is no CONVERTING milligrams to grams, maybe to ounces (ounces=clumsy) .

Lepoe, Haggi did not judge all as thoughtless and careless, only that some are. Mistakes can not be tolerated in things medical. To error is human, yes, for an auto-mechanic, carpenter, or a gardener. Not acceptable in the E.R., doctor's office or operating room, or do you disagree? Mistakes do not happen in today's world. The are allowed to happen, rationalize all you want to make yourselves feel good. Wait until it happens to YOU or a family member of yours. As I already pointed out to saddened, it appears that the general consensus of those patients is "I want to be listened to". So far the nurses and pharmacists on this vine state they can do no better, deal with it, we are human. We make mistakes. Instead of... "We can do better, we are adults." I will not respond to anger or name-calling.

Nurse Dub, your analogy is way off, do not give any criminal credit, jail or prison cannot be compared... most inmates do not have a concsience and deny their guilt. This is about someone who felt culpable and blamed herself to a very lonely end. R.I.P.

Open Mind- I apologize for not using a proper analogy. I was not trying to compare- I was trying to show how one's guilt is more of a punishment than something like jail to a "normal" person.

I cannot imagine what it would be like to have a loved one, especially an infant, possibly lost to a med error. Clearly it did not sit well with this nurse. It is my worst nightmare to cause a medication error or any harm to a patient and that is the feeling of most nurses and physicians I know. You, who are so quick to point out everyone's misgivings, have no idea how much we worry and DO try to do better. When people express sympathy it is not always to rationalize or excuse an action. She made a very grave error. No one can deny that. We DO need to always strive for perfection, but perfection is impossible and if we took away a medical license every time a mistake was made you would be left with no healthcare.

...there is no CONVERTING milligrams to grams, maybe to ounces (ounces=clumsy) .

OPEN MIND JON - you have no clue what you are talking about. The article states that the correct dose of CaCl that the nurse was supposed to administer to the baby was 140 milligrams. She administered 1.4 grams, which is 1400 milligrams. She incorrectly converted 140 milligrams to 1.4 grams in her head. One gram equals 1000 milligrams. She was off by one decimal place, which is why she should not have converted between units in her head but should have done it on paper and then double checked using a calculator. She should have used 0.140 grams, which is equal to 140 milligrams. Trust me. I have a Ph.D. in chemistry and convert between units on a daily basis. The term "convert" is correct whether one is changing from milligrams to grams or grams to ounces.

Every person out there will make at least one mistake in their lives. When I've messed up in my line of work though I could always tell myself that nobody got hurt because of it - being in the arts is low-stress in that department.

However, while I understand that no person is perfect, in her case she contributed to the death of someone's baby. And one thing that stood out to me about the nurse's reaction to it was that it seemed to be all about her: Her 1st sentence on reporting the OD after "I messed up." was "I've been doing this for years", indicating she was thinking of her career first and not the health of the infant. In fact the whole (brief) report was about the nurse: Her sickness and her fear about how it might reflect on her. The baby's not even mentioned.

After losing the job, she was distraught -- not with guilt, according to statements of people who knew her, but because she thought no one would ever want to hire her. I'd like to give her the benefit of the doubt that some of her distress was due to contributing to the death of a child. But it is interesting to me that not one person quoted said the nurse was distraught over the death but all of them mentioned her being upset that her life was ruined.

THX, clear headed response to the article. I do believe that she harbored extreme guilt, after-all, she killed herself. EVERYBODY is subject to being fired from their employment (unless you're the owner) through negligence. Though very few jobs may cost some one's life. That is the crux of the matter. Though I am not surprised by the lack of response from the nurse and pharmacist contingent. Pardon the pun, cuts to the heart of the matter doesn't it? Hospitals are indeed a paradox, at the forefront of expensive (due to stockholders) and tightwad (on services provided) at the same time! Then of course is the bigotry heaped on the immigrant visa nurses...

Being a health care worker (in any capacity) would NOT be something I could do. It takes a special individual to be able to work as a doctor or nurse & do the job well. Too much responsibility but it is rewarding for those who want to do this for their career.

My wife reacted poorly to a sedative given while waiting 7 hours for spinal fluid to be drawn in avery noisy hospital undergoing construction. She was weak and was admitted overnight. She awakened during the night, the nurse failed to read the chart and administered the same sedative causing her to go into a coma and hastening her death. The hospital would not respond to inquiries, basically stonewalled any attempt for accountability. Yes, mistakes are made, but I suggest if you think it is OK in medical treatment situations, you get a job at McDonalds. "we all make mistakes" does not hold up when it is your loved one--it always is someone's loved one.

No one has suggested that a mistake is "OK". However, as long as humans are alive, we will make mistakes. She most likely understaffed nursing unit during a 12-hour shift. Have I had medical mistakes happen to me or people I knew? Yes. Have I made mistakes that could have potentially hurt others? Yes. Is it okay? No. Will it happen and can we learn from our mistakes? Yes.

If you think it's okay never to make mistakes, have you ever gotten in a car accident or been the passenger of one? Even if it's not your "fault" legally, why weren't you more attentive to what was going on around you to prevent it? If you think that you it's impossible to drive without ever making a mistake with a 4000lb killing machine (aka a car), maybe you should walk to McDonalds too.

Amen, Area Man

And everyone wonders why medical bills are so high?

Make a mistake and we'll clean your clock.

Why cant we apply this logic to the us and states govt officials?

Why not wall street---because they are ran by lawyers.

Why are lawyers attacking doctors --- they actually try to help people.

The lawyers are the ones that need to be extinguished.

Incident reports on medical errors never go in a patient record. If you check with hospital records, there will be other documentation in your mother's record about the error. Incident reports are an internal mechanism; there is an entirely different mechanism to report errors in a patient's records. I'm sorry for what happened to your mother, but the hospital is not involved in some conspiracy because it doesn't share it's internal documents with you.

A year ago, my father had several small strokes and after the third one he fell and hit his head. He was taken to the hospital and given a CAT scan. The emergency room doctor showed us what he thought was a small bleed on my Dad's brain. The neurologist looked at the scan and disagreed and said the fluid was a normal amount of fluid for an 84 year old man with the onset of dimentia. We assured him my Dad was as sharp as ever and had NO signs of dimentia. The doctor again disagreed - he was wrong. He prescribed Coumadin for the strokes which caused my Dad's brain to hemorrhage and he died.

yorkdmp, I understand your anger. We had plenty of anger too but we also recognized that it was a mistake. I won't lie and say it was easy, I miss my Dad terribly but there was no malice or negligence involved. He had a different opinion of what the CAT scan said. He was wrong. As many people here have said, EVERYONE makes mistakes. NO ONE is perfect. I am not in the medical field, I can't begin to imagine the pressure of having people's lives in your hands every single day. I have the utmost respect and admiration for those who do and I'm glad they are there.

This is a tragic story with tragic outcomes and my heart goes out to everyone involved.

York... when did this article become about YOU??? Yes, yes... "mom rushed to Intensive Care for Medical Attention"... what does THAT mean?? Doubt you even know the qualifiers for ICU admission and care.

If ANYONE not already in the medical profession had ANY IDEA what it is like on a day-to-day basis to manage acutely ill adults and children, they would be astonished that anyone is even working at a hospital at all.

The worst part of this story is that there is no clear evidence stated that the medication error "directly caused" the infants death. 5 days of NICU time is an eternity when these ultra-critical patients are being actively managed on a minute-to-minute basis. The culture of society (and this hospital specifically) probably harmed more children in the future as it took a talented, experienced, compassionate and HUMAN nursing pro off the front line. Bad decision!

Oh... and while we're at it. Who was around as a caregiver for the nurse? No counseling, therapy, grief management? (that's right... don't you think she had as much, or more, grief than the parents?). An EPIC FAIL for the hospital and the healthsystem in general.

Good luck to us all!

I've worked in the medical profession for over 20 years. I've seen bad doctors and nurses that I wouldn't let touch a stray dog make fatal mistakes and not bat an eye while immediately finding some way to blame someone else. I've seen good, dedicated physicians and nurses who, through fatigue or stress, have made mistakes and been wracked with self-doubt for the rest of their careers. Medical professionals are human. Some of them are good people, some are not, just like the rest of us.

When it comes to hospital administration covering up mistakes, however, you're talking a different story. Since most hospitals are now corporate-owned, and corporations know only one thing, profit, don't put anything past the "suits."

Yorkdmp- I am sorry that your mom and your family had to go thru this one time, let alone three. Here's the thing though: no hospital will place a copy of an Incident Report on a patient's chart or share those with a family. Those reports are strictly for the hospital's use to investigate the incident and see if a procedure or policy needs to be altered to keep it from happening again. If all such reports were automatically placed on the chart and/or handed over to a family, I can guarantee you that many of them would never get filled out. This would be horrific because the opportunity to correct and improve would then never come about.

Nurses are not and never will be perfect. Even "minor" mistakes horrify the nurses I know. I have been a nurse for over 25 years and I still shudder with fear over the thought of a med error. Incident reports must be encouraged so we can change/improve and they must remain separate from a patient's chart so that hospital personnel will not refrain from using them due to fear of a witch hunt.

Also, with HIPPA being as strict on hospitals and divulging of information to famiy members, or anyone for that matter, you will never get copies of anything in your mothers chart. Medical Records makes you sign away your first born for a copy of your own information, much less for family members.

I'm sorry about your experience with your wife but it was not just that hospital's policy to not put an incident on the chart or to give you a copy of the report. That is common to all hospitals. That is an internal way of investigating and addressing errors.

Also, nobody on here has indicated in any way that a medical error is "OK". We all realize how horrible it is but the point we are trying to make is that they DO HAPPEN and they always WILL... because health professionals are human beings. If you create an environment where they are afraid to report their error then we loose an opportunity to learn how and why they happen and to institute better policies and procedures to avoid them in the future.

Just for the record, unless there was more to the story than what is reported here, I believe she should not have been fired either.

york, you sound like the kind of patient every healthcare provider dreads. It is one thing to be an advocate for your Mom. It is another to be an angry person looking and waiting for someone to make a mistake.

You sound too well-versed in knowing the steps for filing a complaint and for procedures concerning incident reports.

If you are so un-trusting of the medical community, leave Mother at home and care for her yourself. It sounds to me as if you want mother to have all the benefits of modern hospital care, but are not willing to trust those who care for her.

There is no compassion in these departments run by Nurses and Doctors. They should all feel guilty at what they are doing to Medical Care. Where is Chris Hansen when you need him?

I get the distinct impression that you dream of a Chris Hanson moment that would lead to a big Payday for you and your family.

you are right..as a nursing supervisor at a large Nursing Home Company we are always told the reports are internal and do not ever even mention them in the nursing notes or medical record in any way shape or form, as when the state inspectors come if it ain't there it didn't happen. I quit that job BTW.

but I suggest if you think it is OK in medical treatment situations, you get a job at McDonalds. "we all make mistakes" does not hold up when it is your loved one--it always is

All well & good to say as a LAY person who doesn't have to work in those environments & really hasn't the foggiest notion of how things function there. Your suggestion is foolish. Only computers can never make a mistake. Computer errors are made by the people operating them. Since computers cannot function as doctors & nurses, doctors & nurses must be human. And they can't will themselves to be other than human.

And there is no way to will away the fact that as human beings, they WILL make some mistakes along the way no matter how good they are, how knowledgeable & well trained, how well meaning, how hard they try not to, etc. You just can't will away the possibility of human error.

CREATUREGIRL, you cannot understand our 'LAY' person view is for their family member to GET BETTER at the hospital? Not worse, nor die? We expect our car repaired, gardening nicely done and children taught well. Be 'PROFESSIONAL'. We complain when our car is not repaired, garden looks like crap, children only taught whats on the SAT's or what the latest doofus on TV is. If you have such a low opinion of who you 'care' for, try being a Police Officer and have your faith in human nature drop...

Easily written criticism from another clinician who has taken a desk job and no longer HAS the opportunity to care for, or unintentionally harm, patients.

another clinician-turned-pencil-pusher who no longer has the duty to care for nor potentially harm someone criticizing the clinician who is still in the line of duty. Way to go Clinical Directors, Risk Managers, Hospital Administrators! Here's to the hope that you have to take a demotion and join the ranks again someday soon ... and deal with someone like YOURSELF in a position of authority. Karma.

I've heard, "nurses eat their young", meaning they're all over new nurses just out of school. And it's true. And nursing depts will attack each other all the time; OR nurses slam ER nurses, the oncology floor will crab about the OR nurses, etc. And yeah, they'll go after nurses in their own section in a heartbeat. Everyother dept will circle the wagons around one of their own.

Hospitals lie.

Nurses suffer because of these lies.

When will the hospitals be held accountable for the situations they put nurses in and the nurses are sacrificed on the alter of the big corporate hospital, their whole lives destroyed.

You are 100% correct. Nurses eat their young. They will cut your legs off rather than look the other way or defend a mistake made by another nurse. Dr's never do this, they Do Not speak against another Dr-EVER!
Unless you have worked in the field, dealt w/the stress, you can't imagine what it is like to wake up from a dead sleep terrified that you "may Have" made a mistake, let alone actually made one and have to carry that day after day.
I have seen it first hand-a nurse on my unit failed to check a man's BP who came in very ill. The man crashed, was coded and died. What they did her after that involved taking all of her documentation, went over it and over it until they could pin negligence on her. From that point she could not move w/o their review or approval of all procedures. They finally wore down and she quit. To this day-nearly 20 yrs later I recall every detail of the event and still would be terrified. I no longer work in acute care nursing but I continue to pray for our Nurses everyday-most do not go into the profession for any other reason that to help care for people and minister to them.

Outrageous for one mistake but the hospital said this wasn't about a single problem. However, due to privacy clauses, they aren't able to broadcast whatever other issues it is about. Which is actually rather kind of them, to not air the woman's private 'dirty work laundry' to the whole world after her death. Whatever she did, it'll stay where it can't harm her family further.

Outrageous for one mistake but the hospital said this wasn't about a single problem. However, due to privacy clauses, they aren't able to broadcast whatever other issues it is about. Which is actually rather kind of them, to not air the woman's private 'dirty work laundry' to the whole world after her death. Whatever she did, it'll stay where it can't harm her family further.

You have no way of know how damaging or outright benign those "other circumstances" may be. It's an easy out for the hospital to let the public mind run wild with the mention of some mysterious other circumstances that may in reality have no bearing at all on this or any other incident or qualifications of the nurse or her job performance.

yep....we are all just one bad decision from the front page of the enquirer---ben affleck.

one bad call = DOOMED!

one "oh, @!$%#!" wipes out about a thousand "attaboys!" Not the way it should be, but too often is.

Sorry, for asking, but did the patient passed away as a result of having an adverse reaction? I always worry about this issue because I am deathly allergic to three antibiotics. Much luck and thank you for sharing.

As a nurse for 18 years I think few understand the stress and demands that are put on a nurse from day to day. It breaks my heart that this nurse who had given so many years to the care of others was simply thrown away and given no support. You are so right the corporate heads and the desk jockey nurses need to stop eating their young.

I am a nurse also. My daughter has an allergy to amoxil. Doctors, nurse practitioners and even their medical assistants miss it on the front of her chart all the time. Medical personnel tend to be over-worked and trying to get through the day and get their job done. Not once did they mention in the article re nurse Hiatt that the hospital understaffs all the time. Which is usually the case in most medical facilities due to Insurance companies and profit. Shame on them for crucifying her for being human.

Allison makes a good point. Rather than reprimanding for 1 mistake, the administrative staff would have been better off by investigating how the mistake was made and insure effective methods to prevent overdosage in the future, by any nurse. Standing behind their staff. This may have prevented the suicide.

This is a truly saddening story. My heart goes out to both families, and I pray they find peace.

I was a laboratory professional for many years and I know technologists that have made mistakes in blood transfusions, one in particular that resulted in the death of the patient! Unfortunately, we in the medical profession, do not have the luxury of making these kinds of mistakes! In the clinical laboratory all of the necessary procedures to prevent this kind of catastrophic result are in place. As medical professionals must always be cognizant of our responsibilities, lives are at stake! To condone these kinds of mistakes is not acceptable. Education and training to the level of absurdity is the solution! Not punishment!

had the person died due to allergies i think u should have been fired and held for murder or homicide. thats it.

I don't disagree, but what has this got to do with this story???

Sure. Let's get rid of "big pharma" and all the other bogeymen.

Now go start collecting plants and scraping bark off of trees ...

I agree. None of us go 24-25 years without making more than one mistake.

We have incomplete information on this case.

My hat is off to those nurses that really care about what they do. They are the majority.

I am especially thankful for those that work with the most difficult cases. One of my grandsons spent months in NICU and there were a lot of babies there that had no chance. There was always at least one death a day, sometimes more, in that NICU. I could not do the job that those Doctors and nurses did in that unit.

I worked for a company and one of my co-workers made a mistake that cost the company $35,000. Expecting to be fired, my co-worker was shocked to hear her boss tell her that he had no intention of firing her and why would he? Her performance in all other areas was exemplary. He knew that the employee would never make that mistake again yet a replacement for her might. Smart man. New guidelines were implemented to help make sure a mistake like she made would not happen again.

This nurse made an error that shook her to her core. Her management team, instead of recognizing her previous record of safety and performance, fired her. The hospital then circled the wagons and did their best to intimate that she had other more serious problems in what I believe was a calculated move to protect themselves from a lawsuit. The family of the infant who died weren't even that vindictive.

The nurse should have received counseling, additional training, and punishment just short of being fired, etc. It could have been used as excellent training material for other nurses. I wonder how being nervous and working under threats and fear is affecting the other nurses there.

We place our medical professionals on a pedestal and expect them to be perfect but of course, humans are not perfect. The inhumanity of her management was perfect, however. My heart goes out to the nurse and her family and also to the baby girl and her family. Two tragedies born of one mistake.

"It didn't sound like this error was the sole reason for her firing"

"Kim has not shown an understanding of how her deviation from policy in medication administration was in any way responsible for this error," wrote ICU Director Cathie Rea. "Her attention to detail and her precision is not what I would expect it to be at this point in her career."

My niece is a nurse in post-operative intensive care at a major metropolitan hospital. She and all the nurses she works with are overworked, understaffed and often put in impossible situations. My guess is that her "deviation from policy" was to either take a short cut or leave other patients unattended or not getting their meds on time or something else that would have put other patients at risk. In most areas of medicine now, staffing models are set for the bare bones necessary under ideal conditions so as soon as something goes wrong or the unexpected happens- which is inevitable- the process falls apart and you're left scrambling to try and get everything done in the time you have.

I'm betting she pointed out the realities of the situation to management so they decided it was easier to fire her rather than fix the problem.

If you read further in the article, it was mentioned that some woman was upset by her hugging her and giving her a peck on the check in an attempt to comfort her. That person thought that Kim was making an advance and filed a report.

If you read the article, as stated above a woman filed a sexual harassment complaint against her. All because she gave her a hug and a kiss on the cheek. I'm sure there were others amongst the staff that didn't care much for her just because of her sexual orientation, and that's just wrong. She made a mistake, and you cannot tell me that NONE of those nurses in that hospital, doctors or higher up paper pushers who fired her have never made a mistake.

I may not work as a nurse, or a doctor but I made a mistake as Pharmacy Technician. It can still haunt you, and thankfully the child lived. Mistakes happen, and even those who are suppose to do a 'quality' check and make sure the prescriptions are typed in correctly miss the error too. No one is perfect... it's just painful when the stakes of the mistake can be so costly.

Mercury, I too read that comment and was disgusted that 1) it was included in the article and 2) that anyone could have characterized that incident as sexual harrassment or misconduct regardless of the nurse's sexual orientation.

It's typically true that it's the perception of the person on the receiving end whose opinion seems to matter most, while too little mind is given to the intent of the person being accused of wrong-doing. The infomation cited in the article don't lead me to think that the nurse was in any way some sort of a sexual predator or that her behavior should have been considered as additional criterial leading to her dismissal.

It seems obvious to me that the goal of the hospital's administration staff was to paint the nurse in as poor a light as possible. No one can tell me that every other medical worker at that hospital who had made a serious or potentially fatal error in the past had also been fired.

My mother was never able to afford nursing school as a young woman and got her masters in nursing as a 42 year-old woman. She was so dismayed by the politics of the hospital where she worked taking precedence over actual patient care that she went into administration after just 7 years to affect changes in policy. My mom told stories similar to this nurse's (that thankfully didn't include suicide) and it made my blood boil.

None of us go 24-25 years without making more than one mistake.

True. That sentence caught me too, though mostly because I wondered why she felt it necessary to even say that. Sounds like something someone would say when they were already afraid they were going to get fired. "I know I messed up but I've never made a mistake in 25 years so please fire me because I'll do better in the future." is kind of how that read to me. Pretty desperate.

Hmmm...incomplete information? Perhaps the writer and editor should be fired for their shoddy performance?

It does not matter where you work or what your sexual orientation is- it is inappropriate to hug someone and kiss them on the cheek in the work place. I am a hetero woman and if a guy did that it would make me uncomfortable at work. I can bet you that woman who accused her of sexual harrassment would have just addressed it with the person if they felt uncomfortable and not gone to mgmt if Kim was not homosexual and that is a shame. The hospital is trying to use this info so they have some dignity in this and I don't think they should have ever released that information because it is tacky to bring up when someone is not here to defend their actions. The bottom line is her death is tragic.

Thank you, Justdontgetit. I'm an ER doctor. Most of the doctors, nurses, and other health care workers I work with really, genuinely care about people - and we all have worked very hard to gain the education and skills to do these jobs. People outside of medicine have NO CLUE what is involved to become a healthcare professional in today's medical climate; it is extremely difficult, and pushes you to mental and emotional extremes. The comments here make it clear that most people have no idea what doctors and nurses do, or what pressure is on us.

People can be so callous toward healthcare workers, just throwing out insults and generalizations, sterotyping thousands of caring people because of one bad experience, or more often, an unsubstantiated opinion. Please have a heart, and be thoughtful about how your comments hurt people - just as you would want to be treated.

I'm on the same wavelength as justdontgetit & D Davis. My heart goes out to both of these families who have experienced such devastating losses. The expectations placed on healthcare professionals is more than is humanly possible to deliver. No one can truely live up to all that is expected. But many that enter the profession do everything in their power to meet those expectations because they know the impact their actions have on the patients they care for. Their reason for entering the profession was to be there and care for people when they need it the most and to make a difference in peoples' lives. To realize you have made an error that hurt instead of helped will shake this kind of person to the core. I am so saddened by this tragedy.

The allopathic professions have long indoctrinated their own with the notion of objective indifference. This is the very reason why doctors have- and to a degree, still- a reputation for being "cold" and "unconcerned".

The fact is, many polls repeatedly answer this question as something that patients do not want. Patients WANT to know their doctor generally cares for them, right, wrong or indifferent. Patients do not want a doctor that treats them as a faceless number, or a meat factory assembly line.

This is not to say that doctors should cross the "line" and risk affecting the "doctor-patient relationship". When there is a power difference within a professional environment (think boss-employee, or officer-enlistee, for example), there needs to be practical boundaries so as to protect the integrity of that relationship. But in no way does this mean that doctors cannot get to know their patients, or go out of their way to ensure due process of healthcare. In some cases, it is prudent for a doctor or nurse to remove themselves from a particular situation, such as treating a family member in an ER due to extreme emotional stress of the immediate situation, but this is on an isolated case basis, and need not be systematized.

There are no studies that show "extra caring" on the part of the health professional leads to distraction or poor performance. In fact, I would conjecture that the opposite is more true. Please re-post if you have any thoughts or references on the matter.

As a pediatric RN and also working adult cancer care, you build a relationship with each and every family. Sometimes you care for these patients for months and years, this is not a small part of your life or theirs. This relationship goes both way, medical staff and families are involved. Sharing FB pages is just part of this relationship and not a bad thing.

Yes, sometimes the relationship crosses the line, but just sharing FB pages isn't it.

When I first got on FB and finding former coworkers, I was thrilled to find out that a couple of the 'kids' I took care of in the 80's, one not expected to live long, were FB friends of another RN. They are both grown, married and doing great!!!

Chances are the relationship she had with the family, them knowing she cared for them and for the baby had a lot to do with the family not suing her and probably the hospital too.

It sounds like she killed herself because she didn't think she'd be able to be a nurse again -- which is doubtful considering how hard up the medical field is for nurses right now. Chances are she wouldn't have even had to move out of state, though possibly to another town. Even if she couldn't pursue a medical career, there are other jobs out there. Many people work in careers they don't love out of necessity. She could have too.

No one boxed her in and left her with no option but death. She made the decision to kill herself because her choice of career was more important to her than her life, her kids or her domestic partner. Which is incredibly tragic for the people she left behind.

if it is true she was "made to feel" this way, then what you say may be as well. But seldom is this the whole truth. And even if it is, the truth that was known was on her side: this was the only mistake she had made in 25 years. Life is rarely so black and white as you seem to make it. There is more to the story than we are privy to...

I doubt this person committed suicide because of a lost career. I believe she was terribly guilty and thus severely depressed.

I couldn't even imagine what this nurse was feeling when she realized what had happened. It would be very devistating to say the least, especially after the baby died.

Anymore the nursing staff is overworked and overwhelmed and short staffed, to many patients assigned to one nurse, mostly due to budget cuts and such, therefore mistakes are bound to happen.

There are times when we have to make the call on a situation that can get us into trouble too. I was a charge nurse at a nursing home on 7pm-7am, to get 40 hrs. they made me come in 3am-7pm. one day a week. I always ended up on the weekend shift, too because someone wouldn't show up. I had worked at this place 2 months. My record before that had been excellent. The mistake I made was not following protocol in sending someone to the hospital. When someone is bleeding. I didn't feel I should be taking time to go through procedures of calling this person and that one before sending them. I was reprimanded for that and told to either resign or be fired. I resigned and wrote a letter which later led to some procedure changes at that facility. I was told this was why I was let go but I was later told by another nurse that my random blood test showed that I was pregnant and that they said I had lied to them about that. I did not know at the time that I was pregnant. I was not suppose to be able to get pregnant again. I'd had a tubal ligation. My youngest daughter will be 16 years old next month.

The medical field is the worsed at turning on it's own. I have not worked in the medical field since. It was a job that I loved, but when I was treated like that, I was devastated to the point I wanted nothing to do with it anymore.

Being a nurse has made me more aware of mistakes I see being made as I have a son and granddaughter with special needs that I have spent a lot of time going back and forth to a children's hospital with. They are little things that the average person probably wouldn't know about but I cringe at because we were taught you don't do those things. Things that you are not to walk off and leave in a room because you forgot something or things you don't turn your back on during what is suppose to be a sterile procedure.

What happen to the "five rights" Right patient, right med., right dose, right route, right time. This is a check that is suppose to be done before every patient is given any med. Some meds even require need more than one nurse checking it. Yes, it time consuming when you have so many patients but it saves lives.

Two nurses in place of every one? Sure, and next you'll suggest hospitals are run for the good of the people-at-large and not the conglomerates fighting for every penny of profit to improve shareholder value...

Typically high risk medications are checked by two nurses. At my clinic, we deal with clinical trial medications, so our orders are checked by two nurses, a doctor, a pharmacy tech and a pharmacist before being checked by yet another nurse before infusion. I don't believe that calcium is considered a high risk medication, so it wouldn't normally be second checked. Of course, in a CCU situation, it would probably make a lot more sense to have things like calcium second checked... and they may do that now after this incident.

All concentrated electrolytes are considered high risk medications and must be double checked by 2 RNs