Welcome to the Medical Legal Podcast, where healthcare. Shawna Butler, nurse attorney. In each episode, we explore gripping real-life stories at the intersections of medicine, ethics, and justice.
From headline-making cases to the behind-the-scenes legal dilemmas that healthcare workers face every day.
In big communities and smaller, lesser well-known ones. Whether you wish scrubs or a soup, these stories are compelling, thought-provoking, and deeply human.
Let's begin. Have you ever considered what the appropriate penalty is for a healthcare clinician who made a medical error?
Does it matter to you if their error led to the end of somebody's life?
Surely there should be some sort of response, right?
But what is that? We are not an eye for an eye society and we know that does not work historically. We want to be an ethical society.
But what about an honest error without malice? Errors are often a culmination of events that lead up to them, and perhaps one person is not solely responsible.
This is what we will discuss today. Stick around and we will get to that.
You can find my criminalization of malpractice course, where material like today, what is in today's podcast, will be covered. This can be found on my site.
At Nurse, attorney, educator, all one word.com. Let's get started.
Kim Hyatt was a critical care nurse working at Seattle Children's Hospital in 2010.
She was considered a veteran. She had an excellent reputation as a clinician for over 25 years.
At this point, she was caring for a critically ill 8-month-old child who had had a cardiac condition that was present since birth.
Kim was due to administer calcium chloride, which was a drug she had been giving for years.
She did note at the time that she was talking to somebody while drawing the medication up into the syringe.
This is the type of drug that is in liquid form, and drawn up, pulled into the syringe.
I'm prepared for administration. If you know anything about safety policy.
safety and medication administration as a nurse. This is an act that has discouraged talking while you're doing it, right? Because it can be distracting. But alternatively, if you know reality, people do not leave you alone.
When you're preparing medications. I recall on a unit I once worked on, we had several signs on the door of the medication room that said, do not disturb. Nurses preparing meds. Do not disturb. Wait till they come out, blah blah blah. You could hang a thousand signs. And this is so we could prep and be ready to administer our medications without distraction.
But sadly, due to the busy and sometimes chaotic environment, this was often ignored.
They would knock on the door, oh, hey, I just have a quick question, and didn't think about it, you know.
In the moment, about how they could be potentially leading to a medication error.
You can see how this can lead to an error in dosage, right?
Sadly, Kim administered 1.4 grams of the drug to the child.
As opposed to the intended dose of just 140 milligrams.
What she ultimately administered was 10 times the dose.
She immediately identified her error. It was her very first medication error in all of her years as a nurse.
It left her devastated. The emotional trauma that these errors can leave these individuals with who are responsible, has been found to be very serious.
There has even been a term coined for it. It is called second victimization. It has been widely studied in the scientific healthcare literature.
I actually did my doctoral work on just this subject.
Let's continue on with the story before we get into how to resolve and what we can learn from these types of events.
She immediately notified the appropriate leadership of the era and logged it in the electronic reporting system, as required, that's what we do.
This is what she reportedly said in the report, quote, "I messed up. I have been giving calcium chloride for years. I was talking to someone while drawing it up.
I miscalculated in my head the correct milliliters according to milligram per milliliter. When you're giving these drugs, I'm interrupting the quote now. You look at how many milligrams per milliliter, and then you draw up that amount of milliliter.
Okay, now I continue with her quote. First met era in 25 years of working here. I am simply sick about it. We'll be more careful in the future.
And end of quote. Being forthcoming and accountable is one of the first things we advise clinicians to do when they're in these situations, regardless of the severity of the error.
To make matters worse, the child dies 5 days later.
Kim was already emotionally harmed long before the child had died, but this certainly did not make the matters improve, right?
She eventually was terminated from the hospital after a temporary suspension period. She was then required to complete a 4-year probationary period by the State Board of Nursing.
Part of this penalty required being supervised while administering medications to patients, which, as nurses and clinicians know, will make it extremely difficult obtaining new employment.
Medication administration is one of the hallmarks of a nursing role in any nursing job, right? So now you need to have a person watch you. How many people are going to be willing to hire you? That means they have to essentially hire two people.
Unless you can find a job that doesn't administer a lot of meds, and technically, you already have a quote-unquote black mark on your record.
It was a known fact that the child was very ill prior to the medication era, and it was never able to be definitively proven that the medication error was the direct cause of the child's death, given their pre-existing tenuous condition.
One of the saddest parts of this story is 8 months later, Kim Hyatt, the nurse.
died by suicide. This has been referred to as a twin tragedy.
While we are heartbroken for the child and their family, we can surely agree that the punishment for an inadvertent error should not be death.
Instead, we need safety stops in place that make it harder to make errors for our hard-working clinicians and their vulnerable patients.
This story is an example of what I mentioned earlier as the second victim syndrome. Of course, the patient and their family are the primary victims, right? And those who contributed to the era, especially when, by mistake, are the second victims.
Those of us who got into healthcare go into it mostly for the exactly opposite reason, right? We want to help people, not harm them. And when the harm comes at our own hands, hands that we want to be healers.
We suffer, too. We never want to be part of the steps that lead to the mistake, and especially, possibly a death, or even really any harm, right?
This term of second victim was coined by Dr. Albert Wu, a professor from Johns Hopkins School of Public Health.
The infant and the nurse both died tied to a series of unfortunate events.
As we have discussed in previous podcasts, most errors occur for systemic, excuse me, systemic reasons. We need to fix the system to prevent errors.
Dr. Lucian Leap, who I've talked about before, and is often referred to as the father of modern patient safety.
has said that one of the single most harmful things we do in healthcare is punish people for errors. Instead, we should pull them into the investigation and find what helped to make the error occur, as opposed to punish them.
Research has also found if you solely fire the individual that was deemed responsible, that type of error could be doomed to recur.
The correct action is to get to the true root causes of the event and remove those barriers. And this part of this is done by completing an investigation by designated staff.
have experience in this, right? They understand error science, risk management, patient safety.
Staff who conduct what is called a root cause analysis. This was something I used to do in a previous role, actually sometimes still do.
This is the process where we complete a root cause analysis. So what does that include? It's identifying and understanding the underlying causes of problems or incidents.
It's an essential tool for problem solving that helps organizations and individuals identify the true root cause of complex issues, rather than just treating their symptoms.
This is done by several methods. You can look it up, there's lots of science behind this.
This is done by intensive medical record review, interviewing the clinicians involved, and maybe those in different leadership positions. So, if it involves medications, we would include pharmacy leaders.
Managers on the units where it occurred, anyone with input, really, knowledge about the way the system works, to see where it broke down.
If there's a medication error, did it start at.
The, um, ordering phase, the provider who inputted the order, the pharmacy that processed the order, the nurse who pulled it out of the medication machine.
There's so many places. Does the medication machine display it in a way that's dangerous? If you're in healthcare, you may have heard of sound-alike, lookalike drugs. That's a dangerous area.
Throughout this investigation, we then identify contributing factors and make recommendations on how to prevent this from happening in the future.
It is also important for aggregate data purposes and for having to report to external regulatory agencies as well.
The death of Kim really highlights a crucial kind of back-end story that most people don't know about.
That nurses, as well as doctors, are so impacted by these kinds of events and incidents when they occur, that the impact could lead to such demise, and Kim is not the only one.
No one is actually safe. It could happen to any of us at any time because of systemic issues.
medication machine issues, a change in pharmacy rollout. It's sort of like a paradox that the nurse would still have to face feelings of guilt, blame, anger towards themselves when they had zero intent to harm anybody. In fact, quite the opposite.
I didn't have years of a brilliant record. This is the second victim syndrome.
Speaking of that, some people do not like the language of second victim. They don't want to be seen as the victim in the scenario when the patient and their family is really the victim.
But experts have not created a better term. There are response groups, like peer support groups, I'll talk a little bit more about that in a moment, but some of them have been called, like, Heal the Healer, or Care for the Caregiver, and some people like that language better than second victim, but I guess it's still a work in progress.
The former my former director of patient safety once said, there's those that have and those that will." And it really can happen to any of us. This is why there's always change in health care and it can be so frustrating a new medication machine, a new IV pump, a new whatever, a new smart pump, right?
And people go, oh, why are we changing it? We have to change. We've always done it that way. Well, some people also say the most dangerous phrase in healthcare is, we've always done it that way, because the truth is, it probably has caused errors in the past.
It can really happen to any of us. Well, what can we take away from this? What can we learn from this before we wrap up?
Safety checks in the system are mandatory. There should be hard stops, where appropriate, not where unnecessary, because hard stops lead to people skipping steps. We want to have the least amount of steps necessary to make a transaction safe, whether it's medication administration or some other act that occurs frequently.
Use the electronic medication record, that's why it's there. Don't do overrides whenever possible.
Use double checks when mandated, follow policies, use checklists. They're all there for a reason. They're genuinely not there to waste your time. And if you feel like they are, put them in the safety reporting system so somebody can analyze it and possibly find a better, more efficient.
safe use of everybody's time. Encourage following guidelines.
And no interruptions at all during medication prep or administration. Respect that process, even if there are signs, even if your question is just a quick second question.
And also, respect and honor the concept of second victims, even if we don't like the term. It is real, it requires intervention for the affected staff.
Many places, as I mentioned before, have peer support programs available for just that purpose. That, as I mentioned before when I said some people call it Heal the Healer, care for the caregiver.
Peer support programs in many places have people who have committed errors in the past and have been through maybe their whole legal process. Maybe they've been sued, maybe they've been brought in by the Board of Nursing, Board of Medicine, and they're beyond it, and they can now provide advice.
So those are the most successful ones. Sue Scott is a nurse.
with a PhD who started a program where everybody gets reached out to by a peer support person and gets a letter saying, you know, you're not alone, we're here for you, how can we support you?
And she, last I knew, so it was probably more by now, but she could cite, like, 2 or 3 people who had made an error, and they were quitting their job. They had a resignation letter in their purse, and they were bringing it, and somebody approached them.
And said, you're not alone. You're in good company, excellent clinicians have made errors before you. So please, take this support, you know, whatever their program provided, and that made people change their mind on resigning from their job, so it's powerful stuff.
If we don't resolve these issues, they will happen again. So know that.
firing somebody is not how we prevent future errors. We have to get to the true root cause. If you just fire the person and it's a systemic issue, it will happen again to another patient. Another thing we actually view receiving more safety reports as a positive thing and not a bad sign.
It doesn't mean there's necessarily more errors, but instead that they work in a culture of accountability and candidness. So when people feel comfortable reporting issues, errors, or even near misses.
that don't even turn into an event. We would rather know more than less, and then we can do something with the ones with, you know, the errors and the near misses before a near-miss turns into an error.
And we cannot forget the response to who experienced the second victim syndrome. Offer support, don't ignore them, don't penalize them, unless, of course, it's egregious, repetitive behavior. Instead, assess them for emotional status and hook them up with support.
And that is really key. We don't want to see a twin tragedy where there is harm to a patient and a clinician.
These clinicians are valuable people, Lynn Hyatt, Kim Hyatt, excuse me, was a valuable nurse with an excellent record, and she beat herself up and felt terrible about this era.
Thank you for listening. On the next episode, we will discuss a case where several residents disturbingly died in a fire in an assisted living facility in Massachusetts in the summer of 2025 and the aftermath of that event.
This was Shawna Butler, nurse attorney. Thank you for listening and I'll catch you on the next one.
Thank you.
Thank you so much for listening to the Medical Legal Podcast. If you enjoyed the show, please take a moment to leave a review on Apple Podcasts. It really helps more listeners find the show.
And if you know someone who would find these stories compelling and interesting, share the podcast with them. Until next time, stay curious, stay informed, and take care. And to all my healthcare clinician listeners, always remember to practice in the best interests of every single patient.
Thank you.
