Sunday, July 3, 2011

Is this a "Just Culture"

First, this is Kimberly Hiatt and she worked at a hospital that  followed a so-called “Just Culture” model, "which recognizes the need to use errors to identify and correct systemic problems, rather than focusing on penalizing individuals”. Many hospitals around the country follow this model today, especially when it comes to medication and surgical procedures.

Kim Hiatt, made her career at this particular hospital for the past 24 years. Last year she made a medical error and gave an infant 10 times the ordered dose of calcium chloride. The infant was not doing well before this incident and did pass away 5 days later, but it is not clear whether this contributed to the baby death. Also, the parents of this baby understood that it was an accident and did not want anyone to take the fall for the mistake.

So here is the kicker. In this so-called “Just Culture” hospital, this nurse was immediately escorted off the hospital property and subsequently fired. She gave 24 years to this hospital and never had a serious mistake prior to this. This happened at Seattle's Children's Hospital, but the truth is it could have happened at any hospital.

Kim committed suicide.

Reading the whole story it appears that there were other contributing factors as to why the hospital was so quick to fire her. Because, even though her co-workers loved her and say she was a good nurse, the hospital appeared to have a problem with her lesbian lifestyle. I am sure there were other contributing personal and professional factors, but that does not excuse how the hospital went above and beyond to penalize her.

Nurses are scared to report errors the way it is, and that should not be the case. However, nurses also have to remember that hospitals are going to look after themselves first. That is one of the big reasons for so much paperwork, hospitals are trying to cover their asses. This makes nurses and doctors do the same thing and try to cover their asses as well.  

This story is wrong on so many different levels


A Doc 2 Be said...

Horrific! From the parents of the infant to the nurse who took her life; from the hospital that deemed her lifestyle choice to be incorrect, to the firing of her.

I'm so sorry to her family, and significant other. It has to be beyond tragic and traumatic.

Cathy said...

That is a horrible, horrific story that bothered me considerably.

It pains me that we still live in a culture where being LBGTstill means you are treated differently. Tragic story.

Zazzy Episodes said...

So very sad!

Cartoon Characters said...

The story left me feeling so sick. I wanted to blog on it but it bothered me so much, I was left speechless.

It's too bad the hospital couldn't have been more transparent...and supported this nurse rather than fire her.

Hospitals extend more help and cover for MDs than RNs...and yet it's the nurses AND the hospitals that would benefit most from their support.

It's all so very sad.

Albinoblackbear said...

What an absolutely tragic story on so many levels.

When I think of every med error I've made in my career all I can say is "there but for the grace of God..."

I've been lucky--because it is a system which requires error prone humans, in error prone situations, to undertake life or death administrations. Until we have a little less blame and a little more effort at figuring out the *systems* that lead to these errors, we are in big trouble.

I recently had a friend (an MD) whose daughter was in BC Children's following a bone marrow transplant, find out that for TWO WEEKS her 3 year old daughter had been getting 5x the dose of narcotic that was deemed 'safe'. No one, not the pharmacist, pain team, attending, residents, medical students, RN's, picked it up.

The Future Missy Prissy RN said...

I have been sitting here shaking my head in disgust and shame because we live in such a cruel word. I am heartbThroken by this story. This is so very sad.

nurse XY said...


Miss Sassy Pants said...

I had heard about this and it broke my heart.