Should nurses be fired for fatal medication errors?

Should nurses be fired for fatal medication errors?Kimberly Hiatt was a pediatric critical care nurse who accidentally gave an infant a fatal overdose of calcium chloride last year.

By accounts, it was a calculation error. A human mistake.

After the incident, the hospital fired her.

This past April, she took her own life.

Although it cannot be concluded that the tragedy was directly responsible for her suicide, the incident clearly took a tremendous toll on her:

“She absolutely adored her job” at Children’s, where she had worked for about 27 years … “It broke her heart when she was dismissed … She cried for two solid weeks. Not just that she lost her job, but that she lost a child.”

Should the hospital have fired her?

Former hospital CEO Paul Levy argues that placing blame on a single person detracts from the hospital’s overall responsibility of improving system processes to prevent future instances:

Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job … It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.

Indeed, when a surgeon was involved in a wrong-site surgery under Mr. Levy’s tenure at Boston’s Beth Israel Deaconess Hospital, he was not punished, as “a ‘just culture’ approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses.”

I agree.

Kimberly Hiatt made a mathematical error that led to the tragic death of an infant patient. Firing her simply absolved the hospital from their share of the blame. Instead, she should have been involved with the subsequent improvement process to prevent future errors.

Now, with her suicide, the tragedy has only been compounded, with no guarantee that it won’t happen again.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

Comments are moderated before they are published. Please read the comment policy.

  • http://www.parentingintheloop.com Lorette Lavine

    Mistakes happen all too frequently…this is a tragedy for this nurse which I believe led to her suicide.

    The hospital should have handled this by following the risk management procedures of tracking the error and putting measures in place to prevent this from happening again.

    Then the hospital should have provided the nurse with grief counseling to help her recover the best she could from this incident which may have led her to take a leave of absence or retire but hopefully she would not have taken her life.

    Now there are two tragedies the loss of the child and also a veteran nurse.

  • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

    No, nurses should not necessarily be fired for making fatal mistakes. I agree there is a double standard regarding the way MDs & RNs are treated and that firing this poor nurse really didn’t solve the problem.

    It is not clear exactly how this error occurred. More details about the incident would be useful. What dose was ordered? Why was the baby given calcium chloride? My experience has been that MDs often prescribe calcium to correct lab abnormalities when it has been shown that patients only need calcium IV when they are symptomatic. Did this baby really need the calcium?

  • http://www.dialdoctors.com Dial Doctors

    Firing nurses, doctors or medical students fails the system. Why? Because mistakes is how we learn. Ask any healthcare provider about the patients he/she remembers. Sure they’ll include a good one but most likely that list will be mostly people they wronged while practicing. I completely agree that by firing her, the hospital prevented improvement in the system, which is obviously flawed because every system is flawed. Find me a perfect one and I’ll give you $100 on the spot. Hiatt worked for 27 years so the law of probability alone made her susceptible to make a mistake. We don’t know what caused her to make that mistake. Was it exhaustion from working too many hours, being spread to thin between too many patients or was it recklessness on her part, e.g. being drunk on the job? We simply don’t know so now we can’t fix it. It’s important to clarify that ‘she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication’, says the article linked to this post. So she admitted to her mistake and simply wanted to get back to work. She even got an advanced cardiac life-support certification exam to be a helicopter transfer nurse and was denied employment despite acing it. This goes to show that mistake and the way it was handled ended her career altogether. Do we end up killing patients due to a mistake? Sadly yes. We haven’t been able to avoid human mistakes despite creating complex systems which evaluate everyone’s work but we’re better. We have improved and we’ve done so by learning about past occurrences not by getting fired.

  • http://www.mdwrites.com MD

    Nurses should not be fired for fatal medication errors unless it is a pattern, or done out of malice. If the nurse is found to be impaired for whatever reason, then obviously she should be fired or at least given the chance to rehabilitate. But a nurse who works hard and makes an error should definitely not be fired. We are after all humans, and unfortunately, the best of us working under the best conditions will make occasional errors, some of which may lead to dire consequences.

  • Muddy Waters

    Mistakes happen. It’s human nature. It’s extremely unfortunate when they lead to harm, but unless someone is a repetitive offender, how can they be persecuted? We learn from our mistakes and become better providers because of them. But, as I’ve said before, the public expects healthcare providers to be superhuman, never get sick, never take a day off and reschedule your appointment, never make a mistake, solve all of your problems in 1 visit, and be completely liable for everything. Oh, and I almost forgot…you dont want to pay for it.

  • SarahW

    Of course she should be fired, if the error was grossly negligent with fatal results for the patient.

    If the doctor ordered a correct dose and she is too incompetent to deliver it to the patient as ordered, even when consequences are slight, there should be review and discipline. A medication fatal in the wrong dose, and a dose any competent nurse should realize is fatal— she belongs nowhere near a patient.

  • SarahW

    Human error is common. Not all human error is on the same scale, and not all errors are tied to competence. Criminal negligence is one thing, but a grossly negligent error that kills a patient is grounds for termination for cause.

    • Julie

      Sarah, are you telling us you have never made an error while working in your life? What you obviously are telling everyone is you have not experienced having a job with such great responsibility as a pediatric RN, or you would not have posted she should have been fired. If you were a pediatric or neonatal RN then you would know that many times these nurses have to calculate the doses themselves based on the patients weight (not the physician giving an order on the exact dose or the pharmacist- the NURSE has to calculate it and is trained to do so). As an experienced nurse myself, I have seen physicians incorrectly calculate pediatric dosages on several occasions. This was a tragedy and human error. She had been a nurse for 27 years and in my opinion, the medical community she worked for failed her miserably and should be ashamed. In a perfect world there would be measures in place to keep this from happening, but unfortunately we all live in the real world where mistakes do occur even though we do our best to minimize them. You have no idea what this nurse was facing on her shift that day and what led up to the incorrect calculation, so you really don’t know enough to say she should have been fired.

  • joe

    Let me guess Sarah…you have never been a practicing RN or MD.
    If you review follow up reports on IOM’s “to err is human” the biggest issue is system’s errors”. Root cause analysis is critical. It is easy to crucify an RN for an incorrect dose of a medication but another question is why was there not a system in place to catch this error? In oncology chemotherapy RN’s all check each others work in addition to the MD and Pharm D’s calculation. In the OR there is the golden moment. Could there be a similar requirement here? I don’t know. I wasn’t there, nor were you. I do know it is easier for an institution to fire an employee than to look at it’s own shortcomings. It is also easier to pontificate on a blog about what “should” be done to a RN who made this error as opposed to setting up a check system to try to make sure it never happens again. Sadly, two lived ended with this event.

    • Nerdy but not a clinician

      She said “IF the error is grossly negligent”, not that it WAS grossly negligent.

      I would guess the vast majority of errors are system-based and/or inadvertent – but some are not. Some involve recklessness or deliberate shortcuts or deliberately covering up pending harm to a patient in order to protect oneself. Maybe this firing was justified; maybe it wasn’t. We don’t really know because no one has released any of the details that would provide some sort of context.

      That said, I’m not going to rush to judgment either way. This was just a very tragic outcome for all involved.

      • joe

        Nerdy, hence my statement
        “I don’t know. I wasn’t there, nor were you.”
        We seem to be saying the same thing.
        Also please see Ningiuem comment and link. Multiple errors with tragic outcomes. This is exactly what Dr Leape was talking about with his IOM f/u reports with systems errors being the main issue.

      • joe

        Also nerdy read what sarah said:
        “If the doctor ordered a correct dose and she is too incompetent to deliver it to the patient as ordered, even when consequences are slight, there should be review and discipline. A medication fatal in the wrong dose, and a dose any competent nurse should realize is fatal— she belongs nowhere near a patient”

        The reality is sarah doesn’t understand even the “best” clinician can make a mistake with a dosing error. That doesn’t make it OK. However, the real question is based on evidence of recurrent significant errors at seattle children’s, why a system wasn’t set up to prevent further errors when the first one occurred. Certainly firing the RN is the “easiest” thing to do. Read Dr Leape’s f/u papers.

  • ninguem

    Kevin, maybe i’ve overlooked it reading the post, but I think you missed an important detail.

    This was not the only medication error with a tragic outcome at Seattle Childrens. They had several of them.

    http://www.kirotv.com/news/25200844/detail.html
    “Death Was Third Fatal Medication Error At Children’s”

    I’ve lost track, I forget if this was the Kim Hiatt case or not.

    I’m not speaking out of school, I’m just relating what’s reported in the Seattle press.

    One can only imagine how many near-misses did NOT make the papers.

    I have no connection to the place.

    I *HAVE* , however, been around the block a few times.

    It’s not hard to read between the lines on this one. I’m willing to bet there’s a system error in the place. What’s especially tragic is the nurse took personally, what I’ll bet is a system error.

    Some administrators should have been fired.

  • Patient

    There should be a better system for disciplining nurses, physicians, and other healthcare workers who make mistakes that result in harm to patients.

    My physician injured me by improperly performing a procedure (verified via testing and a second and third opinion). Nothing was done to discipline her or, better, prevent mistakes like hers from happening again. She or one of her colleagues will probably injure someone else.

    Did I think she should have been fired? Not originally, and not anymore, but right after I found out nothing was done with her: you betcha. There must be reasonable middle ground, though, where errors are addressed but careers aren’t ruined over one serious mistake.

  • Kathy Carlson

    What we see here is a tragedy with no silver lining. I join the millions who are very saddened by this story. As a patient and a mother, I do not expect health givers to be perfect. Anyone who has that expectation is very naive or unwilling to give himself an honest appraisal of his own imperfections. There can be no justice delivered for a mistake, only vengeance. The nurse should not have been fired unless she had proven through her record to be better suited for less exacting work. My prayers are for those who were left to bury their beloved.

  • Nerdy but not a clinician

    According to this statement from Seattle Children’s, they’ve changed their calcium chloride protocol so only pharmacists and anesthesiologists can draw it up in non-emergency situations. So they’re basically admitting the system was faulty… but in the very second paragraph, they state “a nurse in the ICU administered ten times the intended dose…”

    Based on the contents of this statement, it looks to me as if they may have decided to throw this nurse under the bus.

    http://www.kirotv.com/news/25194696/detail.html

  • Jules51

    “To err is human”…..I am sad that Kim felt the need to take her own life. In the medical arena, mistakes are made. Some with tragic consequences. The fault lies with the system of checks & balances. I believe from administration down to the laundry dept should take a mandatory inservice on risk management.

  • Kurt

    It is amazing to me that there are people running health care systems that still today don’t understand the crystal clear systematic patient safety research. Anyone in a position of authority… management or board of directors… should be sued and fired for total deriliction of duty if they don’t understand and institute a culture of learning and safety consistent with what we know today. Running a health care system like that is the equivalent of using blood-letting by barber-surgeons to treat every disease.

  • A nursing perspective

    This is a difficult issue, emotionally and factually. The loss of a child due to nursing error is something that can never be taken back. The child died and what a loss! Some would say the response of the community, news, and medical professionals to the tragedy was a rightful, “How could a competent nurse do that?” Casting blame on that one nurse. However, research has shown that error (medical errors) happen for a reason that is traceable to the origins from the order, to the pharmacy/pharmacist, and then to the circumstances leading up to the nurse injecting the medication. Checks could have happened along the way. For example, in critical care medicine, the dose rate (amount per time) should always be ordered in addition to how much total of the drug the patient is receiving. In other words, the order should indicate very specific directions. If in doubt, the nurse should call the pharmacist, call the MD back, then clarify the order so that the correct order with the correct administration details is written to implement. Suppose this situation was an emergency, or the nurse was emotionally frazzled such as in an emergency, or the nurse was extra fatigued. What we’re missing is the detailed picture of the entire events leading up to the fatal mistake. It just occurred to me that the nurse was possibly in a state of depression after the incident because she felt subhuman to kill a pediatric patient. As a nurse, I can testify to the fact that mistakes happen from all ends. However, the nurse alone is not the only component in safe healthcare delivery. She is likely the last person to touch and impact the patient in a significant way. Sure, she needs to be careful. However, we really shouldn’t judge. Just read Atul Gawande’s books. He has made a mission to speak of human errors, especially in surgery as a surgeon. Human errors are all around us. Nurses aren’t robots and even if we were, we could still malfunction. Although we need to be extra careful in all that we do, we can only try to our fullest to prevent errors. Notice I said, “try”. Intentions being all good and intelligence in place, could you ever dream of a perfect hospital, with a perfect lineup of physicians, and a perfect staff of nurses? That is ridiculous. We can only try to perform as best we can and really care about our patients’ positive outcome. Entrust us with your belief that we will succeed in our defined roles and we will try our darnest. Sincere condolences to both families…

  • William Nuesslein

    My dad was a bus driver, and he hit a man one day. The man died. My dad was not and should not have been fired.

    We had a case in Westchester where a doctor took an oxygen tank to a boy in an MRI machine. The magnets made the tank a lethal projectile. The boy’s family made out like bandits. The doctor’s action was foolish when one thought beyond the boy’s distress.

    • ninguem

      It was a nurse in that case, but of course, everyone was sued.

      Don’t bring ferromagnetic objects near a MRI scanner. As they improve the technology, the magnets get stronger, the danger increases. Here are some examples of MRI accidents.

      http://www.simplyphysics.com/flying_objects.html

  • newnurse

    My 1st job as a new nurse I was thrown on the floor with 36 patients under my fresh wings. How scary does that sound? Believe me it was. When it came time for morning med pass I gave myself 1 1/2 hours to do so. It may sound like LOTS of time but it’s not, not when you are having to do other things like patient care if needed. If you ran past 6am when the next shift was coming on, you were tagged. My first night I got 2 meds mixed up, and realized it on the way home as I am going through what I could do differently the next morning to improve my time. I called my husband crying and wanted to quit right there before I messed up any worse. He quieted me down and said something I will never forget. ‘To err is human honey, you will never forget today’. He was right, companies pile too many patients on to one nurse and expect us to be perfect and never make a mistake. We may be made in His image but we will never be perfect.

  • aek

    It depends:

    I terminated a nurse who not only gave a lethal dose of furosemide, but gave it via the wrong route, did not recognize her mistake when the patient was acutely diuresing and was crashing his pressure, was unable to know to get assistance for resuscitation, was unable to ever cite the correct medication procedure or the drug’s mechanism of action it’s intended effects and it’s adverse effects.

    If the nurse (also applies to any licensed provider administering medication) does not possess the requisite knowledge to administer medications safely and to self-correct/obtain assistance, than those circumstances are adequate grounds for termination due to professional incompetence.

    As previous commenters have noted, a full investigation as to the individual and system factors is required in order to reach an informed decision.

    • Molly Ciliberti, RN

      Why did you hire someone who wasn’t competent to perform those procedures in the first place. I think the “blame” should be shared by you for not knowing that he or she didn’t have the requisite knowledge to administer the medication safely and putting him or her in that position. You set the ball in motion and put the patient in harm’s way.

      • aek

        Good question.

        I didn’t hire her. I was a newly (within 6 mo) hired unit manager, and this nurse was hired before my arrival. She had no prior record of practice concerns.

        But you bring up a great point: licensed providers need to provide evidence of competence, and excepting for licensure exams and employer-based orientation assessments (of which there are no national standards for content), there are no comprehensive systems in place to assess for competence on every medication, procedure and treatment. There is only a general correlation between successful completion of licensure exam/board certification exams and clinical competence.

        • Molly Ciliberti, RN

          Thanks for your response. I guess it behooves us all to Perform an actual due diligence on prospective employees including speaking to references. It helps to do periodic peer reviews as long as they are handled correctly, just in case there is a nasty person who for their own reasons likes to dump on others. When I was briefly a manager (hated the hours 7AM-3PM too early wakeup time) I would ask her references (if they were former co-workers) and in the peer review her/his co-workers: “Would you feel good about having X as your nurse if you were very sick?”

  • http://www.PeerReview.org Richard Willner

    This nurse absolutely should not have been fired. If she needed help, the Center for Peer Review Justice would have helped her immediately. The phone is even answered 24-7 for emergencies. There are solutions besides killing oneself.

  • http://www.thenerdynurse.com The Nerdy Nurse

    You are right. This tragedy could have been used as an opportunity to improve an obviously flawed process. To Er is human and this an an example how even a 27 year nurse can make a simple mistake that can cost lives.
    Should the hospital have fired her? I don’t know. I am very glad that I am no a part of that ethics committee. She made a mistake that cost a life. There will be nothing than can ever be done to correct that, but how many lives over those 27 years did she save?
    The guilt she no doubt felt for loosing that child haunted her to the point where it caused her to end her own life. Did he hospital firing her contribute to this? I think so. If they would back their nurses, rather than putting their backs to them when the poop hits the proverbial fan, they would have a much stronger team of healthcare providers.
    Mistakes happen. Nothing can ever explain or makeup for the death of that child, but killing someone else’s spirit by taking away their livelihood, their passion, their life’s work is not the best answer.
    As a mother, I cannot say for sure what I want would if it had been my child. I can’t imagine. But as a nurse, I know that the guilt she must have felt would have been unbearable.

  • Molly Ciliberti, RN

    Seattle Childrens had quite a few very serious and some fatal errors and I feel that shows a problem that is system wide. I vividly remember the two mistakes that I made as a nurse although they were a long time ago. I was lucky and there was no harm, partly because I found my own error right away and acted to correct it each time. I also told the patient and their family, the physician and my superior right away. I still feel awful about it. None of us should sit in judgement without all of the facts, but so many errors at one hospital around the same time with different personnel tells me that the hospital has some serious problems that it needs to correct and it might be wise to bring in fresh eyes to help find them and correct them. This double tragedy of two needless deaths is so very sad.

  • http://www.PeerReview.org Richard Willner

    The reason why the concept of “Medical Malpractice” exists is that the occasional human error that, yes, may lead to the death of a patient is handled in the civil courts and not made a criminal matter.

    If medical mistakes become a criminal matter, that will quickly empty the Nursing Schools as well as the Medical Schools. Isn’t that logical?

    I am proud to say that the Center for Peer Review Justice that I started 11 years ago to fight Sham Peer Review and the liability shifting of hospitals is here to serve the Nurse or Physician 7 days a week.

    One can call us in complete confidence and talk out one’s problem. We listen closely and we have solutions that have been tested over 11 years.

    There is no need to be alone. There is no need to have no hope.

  • Norm

    the individual involved in the case referenced by Mr. Levy involved a physician. It is not that unusual that a physician’s error is handled differently than that of a nurse or another hospital staff member. Is it just culture or just nonsense?

Most Popular