Unique Closure


This week I reviewed Washington State Nursing Care Quality Assurance Commission records for Kimberly Hiatt—the 1,500 pages allowed under public disclosure. I had requested these records in order to look at the primary sources unfiltered by journalists or people close to the case. I also requested them as data for a journal article I am preparing on health workforce regulatory systems. Kim’s story continues to disturb me. I won’t repeat her story here, since it has been told in many other places (and most completely/accurately in my opinion by JoNel Aleccia/MSNBC). Instead, I will share my main impressions, thoughts, and unanswered questions.

My overarching impression is that the entire cascade of events contributing to Kim’s suicide could have been prevented. A secondary impression is just how complex our health care system is—how prone to errors of all sorts, not just medical errors, but errors of judgment by people in various levels of the healthcare hierarchy. It is not any one person’s—or one institution’s—fault. However, all along the way, individuals with power could have significantly altered the course for Kim. And nurses were turning on other nurses within this cascade of events. Not only nurse administrators, but also nurse colleagues of Kim’s. (I should note that there were also nurse colleagues who were quite supportive of Kim–and these show up in the record as well.)

But some of Kim’s colleagues were making unsubstantiated accusations, including a sophomoric and trumped-up sexual harassment charge by seemingly homophobic co-workers (and from the record, not handled well by hospital HR). This sexual harassment charge by a female nurse against Kim involved the fact that Kim was openly gay. That this could happen in a modern-day US hospital is dismaying. That this could happen in a US hospital in a city with the highest per capita population of lesbian-identified women is appalling. Then there was the more recent charge (by an ICU nurse) of Kim abandoning a patient. An investigation of this charge found that physicians had called Kim into help with a difficult parent conference, and Kim had arranged coverage for her patient.

Nurses could have prevented the negative outcome: shame on us.

Kim had worked at Seattle Children’s Hospital for 24 years on several different units. This was her first major medical error. The Cardiac Intensive Care Unit where Kim worked had just offered her a permanent position. Her last performance review dated 8-24-10 signed by the Director of ICU rated Kim’s performance as a 4/5 “Leading Performer.” Annual job performance reviews going back to 1994 are similarly high, with a peer writing, “Without a doubt, Kim is one of the most skilled nurses on our ICU.” Then, immediately after the medication error, in a report to the Nursing Commission, this same Director of the ICU (and a nurse herself) expressed concerns about Kim’s nursing practice—that she “failed to partner with leadership and work to correct the situation that could have caused her to make the failure.” Kim had immediately reported her medication error—had helped the medical staff remedy the situation—had disclosed her error to the baby’s parents with the support of the lead physician—then had been escorted off hospital property/put on administrative leave, and soon after was fired. Where exactly was Kim’s failure to partner with hospital leadership?

The initial report of an adverse event sent from Children’s hospital to the Nursing Commission stated: “an overdose of medication to an infant, who died as a result” even though it was not clear (and remains unclear according to the medical examiner’s final report) that the overdose contributed to the baby’s death. It was also reported this way in a memo by the CEO of Children’s hospital—that was then picked up by KOMO News and the Seattle Times. Guilty until proven innocent. The Nursing Commission member’s e-mails/memos acknowledge this “heavy media attention” as pressuring them to make Kim’s ‘case’ high priority. How might this have prejudiced the Nursing Commission’s decision-making process for Kim? The Nursing Commission member in charge of Kim’s investigation is herself a Chief Nursing Officer of a hospital. How might that lens have affected the Nursing Commission’s decision-making process for Kim?

The Nursing Commission refused Kim’s lawyer’s repeated requests for copies of their complete investigative materials—including the final medical examiner’s report—so that he could adequately advise Kim on her options before she was required to sign the final Stipulation of Informal Disposition (the final disciplinary action/sanctions). Why was his request denied?

The Stipulation sanctions included a $3,000 fine, 48-month probationary period where Kim needed supervision for giving medications, Commission approval of any future jobs, and reporting of her discipline to the National Practitioner Databank—as well as made public on the Department of Health website. The Department of Health staff attorney assigned to this case wrote in an internal e-mail “Talking Points” prior to the final settlement, “Tell (Kim’s lawyer) his client may take it or leave it…” Kim signed this Stipulation. A week later she killed herself. Upon being notified of her death, the Staff Attorney for the Nursing Commission advised closing Kim’s case as “a unique closure.” As of today, Kimberly Hiatt shows up in the Washington State Provider Credential Search Database as having an expired nursing license and having had no disciplinary actions.

What does all of this say about the deficits in our health care system? What can nurses—and others—do to prevent this sort of treatment of a nurse? Can anything be done to reform the health professions regulatory system? Can anything be done to hold hospitals accountable for their treatment of nurses?

I realize that it is easy for me to say that nurses need to speak up more about injustices to other nurses, to stop petty in-fighting and not so petty back-stabbing. I am–as spokespersons for Children’s hospital refer to us–an “armchair safety expert who doesn’t know the details of Hiatt’s case.” Except I do know 1,500 pages of details of Hiatt’s case. It now makes less sense to me than it did before. There is no suitable closure–not even a unique closure–for Kim Hiatt’s case.

KOMO News Problem Makers

Original cast of the show (1994-1995)
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Tracy Vedder with our Seattle-based TV KOMO News Problem Solvers should have been at our panel discussion yesterday on med errors and the consequences for nurses. Perhaps she could have learned something. But instead she was hot on the case of two Seattle Children’s Hospital nurses who were charged with professional misconduct yesterday by the Washington State Nursing Commission. Last night she aired a news piece that sensationalizes and distorts the facts.

The online link to the video news portion is bookended by an ad for UNICEF. A mop-headed sad-faced boy says, “22,000 children die every day for reasons the world has the power to prevent.” It then cuts to the two newscasters sitting behind a desk with a large screen in front stating in large letters: “Nurses Charged”. Then Tracy Vedder is shown in front of the Washington State Department of Health, and states that two Children’s Hospital nurses were charged with unprofessional conduct—with SERIOUS conduct violations (her head spins around to emphasize ‘serious’). She goes on to name the two nurses several times. She describes the transport nurse as giving three medications “without any doctor’s orders” and says the baby in that case died. She states the ER nurse gave an adult patient epinephrine by IV instead of IM. The patient had arrhythmias but was stabilized.

Ms. Vedder fails to mention that the medications the transport nurse gave were appropriate ones, that the medical examiner determined the baby died of natural causes, and that both state and federal authorities cited Children’s Hospital with a lack of clear guidelines for transport staff.  Tracy Vedder also fails to report that in the case of the ER nurse, an ER doctor incorrectly prescribed the epinephrine to be given IV, but was not charged because he “didn’t intend any harm.”  All of this information is in easily obtained publicly available documents, including official written statements by Dr. David Fisher, Medical Director for Seattle Children’s Hospital.

By contrast, Carol Ostrom (please note, this is her correct name–not Tracy Ostrom–apologies Carol!) of the Seattle Times has a remarkably balanced and insightful article today about the nurses being charged. She was at our panel discussion yesterday, but I draw no cause and effect conclusions. I think it was a case of selection bias. Yesterday in the panel discussion, NPR’s Joanne Silburner encouraged the audience to be responsible consumers of news media, and to recognize the limitations of TV news. She also encouraged nurses in the audience to speak out more, to know which newspaper reporters are professional (including ethical), and to talk with those reporters when given the opportunity. I would add: stop watching TV news. Lead by example.

The other lesson I learned yesterday: Kim Hiatt’s suicide should be a “never again” event, and all of us have a responsibility to ensure that is the case. Two of our nurses in Seattle are being publicly fried by KOMO News and others. Let’s not be silent about that. In whatever ways we can, we should each offer appropriate support to these two nurses—and to all of the ‘collateral damage’ nurses who know and have worked with them.

To Err is Human: Medical Errors and the Consequences for Nurses

The Neonatal Intensive Care Unit.
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That medical care can be harmful to your health or even deadly, is not necessarily news to many people. The extent of it within the US health care system and the impact of it on health care providers are not well known. The IOM Report To Err Is Human: Building a Safer Health System (2000) highlighted serious patient safety issues in our health care system and outlines approaches to patient safety improvement. This report emphasized that the vast majority of adverse patient events were the direct result of bad systems and not of bad health care providers. “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” They pointed to the aviation industry as a model for safety design at the systems level. Root cause analysis was applied to understand and try to prevent adverse events. “Never events” were identified as sentinel patient safety events for monitoring purposes in hospitals (these include surgical removal of the wrong body part and inpatient suicides). National level patient safety monitoring databases were developed. Eleven years later where are we in terms of progress on patient safety?

In the April edition of the journal Health Affairs, indications are that we have not improved much and may actually have worsened. A study by Classen, et al reveals that serious preventable adverse events occur in one out of every three hospital admissions. Another study estimates a $17.1 billion annual cost of measurable medical errors in the US.  They point out that the risk of harmful errors in health care in the US is increasing due to the increasing complexity of care and of medical devices and medications. What to do about this? The Agency for Healthcare Research and Quality is putting an emphasis on educating patients on ways to advocate for their own patient safety (or parents of pediatric patients). But as Donald Berwick points out in the April 15th Health Affairs Health Policy Brief on improving quality and safety, “Commercial air travel didn’t get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too.”

I have been thinking about the issue of patient safety and the consequences for nurses because of the recent news of the suicide of a respected local RN, Kimberly Hiatt. She died April 3rd at the age of 50. She had worked as a NICU nurse at Seattle Children’s Hospital for almost the past thirty years. I did not know her personally, but by all accounts she was a devoted and highly capable and compassionate nurse. In fact, Megan Moreno, a pediatrician who did her fellowship at Seattle Children’s Hospital and whose daughter Fiona died in the NICU of congenital health problems describes Kimberly Hiatt in an article published in the Archives of Pediatric and Adolescent Medicine (January 2006). She writes, “Our favorite nurse was assigned to us the next day, and she helped us through the difficult task of extubating Fiona.” At the end of the article she expresses particular gratitude to Kim Hiatt, RN, along with her neonatologist.

Kimberly Hiatt committed suicide because of a cascade of adverse events that happened to her in the aftermath of a medication error that resulted in an infant’s death in the NICU at Children’s. This happened in September, 2010 just months after a highly publicized death of a 15 year old autistic boy after routine dental surgery at Children’s, which resulted from an incorrect dose of a Fentanyl patch (a powerful narcotic) prescribed by the dentist. Children’s Hospital changed its policies on the prescribing of narcotics after this incident, but the dentist was not disciplined. Around the same time, an ER doctor at Children’s incorrectly administered a drug to a critically ill patient by IV instead of by an injection in the muscle, and the patient had to be transferred to another hospital because of the complications. The physician was not disciplined.

In contrast, Kimberly Hiatt was fired soon after the infant’s death. Also soon after the infant’s death, Children’s Hospital changed its policies to require stricter control and checks on the administration of the specific medication, calcium chloride, which is considered an especially dangerous drug  in medically fragile infants.  Dr. Hanson, the Medical Director of Children’s Hospital said that it was important that all staff feel safe to report mistakes. The Washington State Nursing Commission put restrictions on her nursing license with a four-year probationary period; with these restrictions no one would hire her to work as a nurse. According to a Seattle Times article (4-20-11), many hundreds of former patients and their family members, as well as nursing colleagues attended her funeral. In the Seattle Times Editorial and Opinion pages today, F. Norman Hamilton, a retired anesthesiologist writes, “The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error. (…) If we fire every person in medicine who makes an error, we will soon have no providers. (…) It is my belief that if the nurse had been dealt with appropriately—with compassion and insight—that she, today, would be a valuable and happy nurse.”

So 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—and usually due to unsafe staffing levels they have no control over—what do I teach my students to do? If the suicide of a hospital patient is considered a sentinel “never event,” shouldn’t the suicide of a nurse such as Kimberly Hiatt due to systems errors be considered a “never event?”