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."