By PAUL LEVY
The sad case of Kimberly Hiatt, a Seattle nurse who committed suicide months after being disciplined for administering a fatal dose to an infant, is starting to make the rounds. Josephine Ensign, for example, concludes her blog post on this by saying:
I am left with many questions. Why was the nurse treated so differently from the dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes . . . what do I teach my students to do?
We can never know, of course, whether the suicide was related to the incident itself, the disciplinary action, or indeed, some other aspect of Hiatt’s life. But the sequence of events will cause many to draw the connection between the way Hiatt was treated after the accident and her death. In any event, though, the ambiguity as to whether or not it was connected does not take away from the kinds of questions raised by Ensign.
Captain Sullenberger raised this issue during his talk at MIT this past week. Citing this particular disciplinary case, he noted that the kind of approach taken was “not particularly helpful” in creating an environment in which crew resource management would be effectively implemented.
My regular readers know that my former hospital faced a similar issue following a wrong-side surgery. Would we punish the surgeon and others involved in the case? We decided not to, not because they had suffered enough themselves from the error, but because we felt that 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. The head of our faculty practice put it well:
If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if these staff members are not punished than if they are.
Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job. As Tom Botts from Royal Dutch Shell commented about deaths on one of his company’s oil rigs:
It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organisation to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.
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.
For over two-and-a half years, the IHI Open School has been using our approach to this case as a teaching tool, simply asking: “What do you think of the way the hospital responded to the error? What should happen next?”
There are now 123 pages of comments on the Open School website, and every day my email forwards several new ones to me. It is clear that this kind of issue raises strong feelings, and it is healthy for the debate to proceed. It may be that there cannot be universally applied principles, that each case is sui generis. But, even if we can get each hospital to consider the question — before applying punishment — If our goal is to reduce the likelihood of this kind of error in the future, what is the best course of action? — then progress will have been made.
Still, I cannot think of Nurse Hiatt without crying, for her, her loved ones, the baby, and the baby’s loved ones. Sully said it well, “”I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country.”
Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.
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This is an extremely helpful post, if most would notice the smallest blunders that we receive from the field of medical service and do something about it, more people will be rid of ailments.
i think that is the best wish to the world.thanks
I am not an ENT physician, but maybe his treatment (what you call a TAMPON) was appropriate? That the other doc did something different, esp. when urgently requested, doesn’t prove anything (both treatments may have been reasonable, or maybe just one of the 2 treatments, and the other one being under- or overtreatment).
I agree with your last 2 sentences, though. Doctors are highly educated and paid professionals (I would admit a lot are overpaid even though I am one myself), and they are much harder to recruit than nurses, even considering RN shortages (esp. in rural areas where one has to drive 40 miles to the next hospital). They also have more clout with administration … in that sense, one could speak of a white wall. But if you are talking about jury trials, or metropolitan areas, I think the situation has changed considerably.
Do you really think that? You must have no experience near where I live. As a Doctor gave a friend of mine a TAMPON to put into his nose when he got a severance nose bleed in the winter. He is a hemophiliac and has a weakened immune system. His family came in asking for it to be cauterized and he denied that request saying it wasn’t necessary. They had to drive to the hospital 40 miles away to get treatment. They never even got a form letter from the hospital and there was not any disciplinary action taken other then he had to take some English classes at the local hospital. This is a fairly small town. Everyone knows everyone, and my aunt is a ER nurse. She new exactly who we were talking about when we asked her about him. He didn’t have his contract renewed a year later for some sexual harassment issues. yes i know these are totally different in scale, but this is the normal. My aunt and mother in law are both life long nurses and they know of times when the nurse has been in trouble for doing what they were told from the doctor and the doctor didn’t get in trouble for telling them to do it. Saying that there is no white wall for the doctors is just like saying that rich and poor are treated equally by the medical establishment.
Chris, I think you should specify what you mean by “white wall”. I think you are referring to something that, in the US, has ceased to exist (or at least partially broken down) over the past decades.
This is tragic and, in my opinion, an example of the “white wall” of protection for physicians. I say “white wall” in reference to the ephemeral “blue wall” of silence that protects police officers who’ve engaged in less-than-stellar behavior.
That nurse was on the bottom of the totem pole and she suffered for it.
Now, as a former journalist, I’m also inclined to want to know her disciplinary history, but the story is still a poignant example.
Thanks for this post.
Thank you for this blog note. I recently had a similar incident in a hospital where I work. where a nurse made a calculation error on an immunosurpressive drug in a transplant patient. The administrative
approach was to suspend her immediately. Fortunately the nursing directors
often work closely with physicians in my hospital and in polling for my opinion
I pointed out several things including that in bioethics the approach should not
be punitive but work to resolve the primary conflict. In this situation we had just move a very large hospital. Nursing , MD and Administrative staff all working
beyond resonable hours in a resource stressed setting. However , nurses run the most risk ( just after patients) and in the justice arrray should have the benefit of protection. I explained that as a doctor I was trained to “want her head” but as a bioethicist on the bioethics comt – I thought it rediculous to negate the learning curve and stresses we had been under, suggested supervision and that the nurse involved should become the “transplant drug ” expert on our unit, sent to inservices , spend time with nursing staff supervisors adept in chemo therapy — It was a novel approach for the nursing supervisor but she went with it. I do believe that more cases like this need to be brought to ethics committees for resolution – and that those committees should work toward increasing competence instead of punitive actions. My heart goes out to the family of the nurse who gave her life.