This morning, in the The Seattle Times, there is a story that has brought me to tears. The story of this Seattle Registered Nurse (RN) is so poignant. It is impossible to feel anything but sorrow for both families surrounding the lives lost due to a medication error made by this very experienced RN.
This brings to the surface the stress and fear, that as nursing professionals, we all feel. The possibility of making 1 mistake; losing the life of your patient, the livelihood you as a professional has worked to cultivate, and the life you have worked to establish. It doesn’t matter how careful you are every minute of every shift you work-mistakes happen. The work and personal lives of Registered Nurses are interwoven. There are so many days in which the shift ends, you give report to the next nurse, but you take the worry and concern for your patients home with you.
The few medication errors I have made, have been easily resolved without any negative or even noticeable impact on the patients; I remember both of them very clearly. I am completely unable to fathom the personal shame, embarrassment, and stress that this RN felt after making a medication error in which the life of a child was lost. It is even more tragic that this medication error has now claimed two lives.
The story of this medication error was highly publicized in the Seattle area. Though, from the viewpoint of a professional, the details of the error were not made immediately clear. I did not know until I read the newspaper this morning that the RN caring for this little girl had worked for 27 years at that organization and I didn’t know that she had been fired from the hospital. Much of information available in the news about what occurred that day was based on the blog by the parents of this beautiful little girl. They mentioned the calculation error on the part of the nurse, in relation to the administration of the calcium dose, as the cause for further decline in the condition of their daughter. While I did not read the blog myself, it seemed information was disclosed to them, by staff, at the time that the error happened. There didn’t seem to be anger and blame mentioned by the family in the blog excerpts that were available in the news. The hospital CEO discussed in an article in The Seattle Times about 10 days after the news of the death Kaia Zautner was released initially; for the need for a full review of the error that occurred and the importance to create a culture in which staff and the institution were open about medication errors so that the systems and processes in place could be evaluated and changed.
When I try to examine this situation from an objective viewpoint there isn’t any information available to the mass media about what the specific process was that was in place for calcium administration in the ICU at this hospital. Were the nurses allowed to draw it up and give it, was a safety check missed or skipped in the process of administration of this medication? After this terrible mistake, what changed within the organization besides not letting nurses draw up this medication? Why was she let go from the organization that she worked at for the length of her career when it would be assumed that she had a very safe practice record? Was there negligence on her behalf? Was she scapegoated and blamed for the incident? The state did not revoke her nursing license- would teaching, education, and monitoring at the bedside have been a possible option even?
I do not nor have I ever worked at Seattle Children’s Hospital- so I do not know much about the culture of practice within the organization. It is a well-respected cornerstone of practice and clinical excellence within the region for the care and health of children. I will however remain curious about the details of this incident professionally for a long time.
It is difficult for me to put into words the emotion I have surrounding this story. I am deeply saddened for the family of this little girl. I can’t imagine the pain that would have resurfaced for these parents reading this story in the newspaper today while they are still working so hard to heal and move forward as well as honor the memory and life of their daughter that was taken from them much too early.
With the deepest respect I wish both families peace in this time of turmoil. May the lives of Kaia and Kimberly be remembered for the joy they brought to all those around them.