Sunday, May 15, 2011

Tragedy in the PICU: Death of a child and her nurse

There has been a story circulating the blogsphere recently about a PICU nurse, Kimberly Hiatt who took her own life after making a medication error that lead to the death of Kaia Zautner.

Based on what I could read Kaia had congenital heart disease and was on a Berlin Heart (machine for patients with a failing heart that helps the the heart pump blood). Often children are on this device to keep their heart working until they can get a transplant. She was a fragile child. The nurse, who had been working for 20+ years,  gave the child a dose of calcium chloride that was 10 times the ordered amount and as a result the child died a few days later as a result of complications from this.

Having taken care of a child on a Berlin Heart back when I was a fellow and personally given and ordered calcium chloride I can totally imagine how this could have happened. Calcium is a very tricky drug to work with. First off when a doctor asks for "calcium" there are a few different dosage forms that one can order each with very different doses. Second, when we dose calcium some people dose it by "milliequivalents" which is how we dose other electrolytes like sodium or potassium while others will dose it by milligrams like we dose other drugs. Over the years I've seen several errors where people mix up the milliequivalents and milligrams. Thankfully the errors were caught or no one was hurt. Third, calcium chloride (which was what was given in this case) is often used in emergency situations where patients have dangerously low blood pressure, a problem with the heart rhythm, or worse are in cardiac arrest. During these types of situations the normal safety checks breakdown since drugs are prepared quickly. (I'm not sure what type of situation the drug was given in here).

In reading some of comments on the stories/blog posts I read several posters who felt that the nurse should be severely punished for her actions. Doing this will neither bring back the child or improve the care. I think when a tragedy happens that could have been prevented we look for someone to blame. While it's true there are medical professionals (nurses AND doctors) who are "bad apples" the vast majority of errors occur from what is  called the "swiss cheese model". In a nutshell, we are all like pieces of swiss cheese and could potentially make an error. However, all of our "holes" are in different places so we can catch errors that others make when we check each other. However, sometimes all the holes line up and an error happens. For example, if you order a medication in my PICU, there is a dose checker in our computerized ordering system, then if you override that the order is checked by a pharmacist. Finally, the pharmacist sends the drug up to the floor and the nurse checks the med again against references and with another nurse. This system which is pretty typical for Children's Hospitals sounds air-tight but is not infallible. To make matters worse the nurse is often the last line of defense between any errors and the patient. As a doctor if I write a wrong order it will hopefully be picked up by a pharmacists or the nurses who double check me. However, if a nurse makes an error it goes right to the patient.

I think this tale highlights two things that are important in healthcare that are often overlooked: emotional support for the healthcare team and the importance of patient safety.

Working in healthcare, especially with critically children, is emotionally draining. There is constant pressure from higher ups, other members of team (nurses at doctors, doctors at nurses, etc), parents, etc, etc all this while trying to provide good care. When a death or other particularly intense event happens we often don't have time to stop and take a breather. Also, many people feel that those outside the medical world can really understand what they are going through. Often after an event like this we will have a debriefing to let everyone get their feelings out. While this helps the initial sting I think for many more follow up may be needed. Also, it is estimated that medical errors lead to the death of 40,000-100,000 people a year. Unfortunately for hospitals strategies to reduce medical errors do not draw in customers like say purchasing a new MRI machine. Hopefully, events like this will bring more focus on the importance of patient safety.

Blogs that have discussed the story:
Not Running a Hospital: I wish I were less patient

Should nurses be fired for fatal medication errors