The Layers of a Medical Error

The April 3, 2011, suicide of a nurse who administered an improper dose of calcium chloride, 10 times the appropriate amount, which may have led to the death of an 8-month old baby, has brought national attention to the issue of reporting of medical errors. Though the reporting of medical errors is certainly a topic with vast depth (for a more in-depth look, please visit Reporting Medical Errors), and the safety of a patient is the focal point for health care providers, an interesting aspect of the story of Kimberly Hiatt, nurse in the Cardiac Intensive Care Unit at Seattle Children’s Hospital, is the impact of medical errors on the individual making the mistake. This is termed the “second victim” by Dr. Albert Wu, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. Dr. Wu’s concept, coined a decade ago, describes the second victim as the health care provider who made the mistake which led to the harming or death of the patient.

For example, the MSNBC article discussing Nurse Hiatt’s suicide mentions that Surgeons who believed they made medical errors were more than three times as likely to have considered suicide as those who did not. Here, Nurse Hiatt claimed this was the first serious mistake she had made in 25 years of nurse practice. Nevertheless, she was fired from her position within weeks.

Seattle Children’s Hospital officials indicated that they have used a model since 2007 which recognizes the need to use errors to identify and correct systemic problems, rather than focusing on penalizing individuals. Officials also noted that employees are not terminated due for “simple human error.”

This tragic story is certainly thought provoking and touches upon various areas of discussion within the medical and insurance community.

Author: Drew M. Rothman

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