Kim Hiatt had worked as a nurse for 24 years when she made her first medical error: She gave a frail infant ten times the recommended dosage of a medication. The baby died five days later.
Kim’s mistake was an unnecessary tragedy. But what happened next was an unnecessary tragedy, too: Seven months after the error, Kim killed herself.
“She fell apart,” her mother, Sharon Crum, says. “I suppose it would be the same thing you would feel if you felt you were at fault for a child’s death.”
This is a story about Kim Hiatt, the mistake she made, and how she struggled with that tragedy. It is also a story about an open secret in American medicine: Medical errors kill more people each year than plane crashes, terrorist attacks, and drug overdoses combined. And there’s collateral damage that can go unnoticed: Every day, doctors and nurses quietly live with those they have wounded or even killed. Their ghosts creep into exam rooms, and seeing new patients can reopen old wounds.
It’s easy to write off the anguish of these health-care providers as insignificant next to that of the patients and families they’ve hurt. They made horrible, harmful mistakes. Maybe they should feel bad. But clinicians don’t exist in a vacuum. In the wake of an error, they have to keep seeing patients and performing surgeries. If they don’t regain confidence in their skills, other patients could suffer. Getting past this danger zone will require a shift in medicine, away from a culture that sees mistakes as unspeakable and toward one that recognizes that medical professionals suffer tremendously when they inadvertently run afoul of their sacred oath: “First, do no harm.”
“The best word I can use to describe that day, and really the first couple of days, is isolated,” says Rick van Pelt, an anesthesiologist at Brigham and Women’s Hospital in Boston who nearly killed a patient during a routine surgery in 1999. “There was no way to communicate effectively what had happened. What do you say when you almost killed a patient?”
Medicine ran in the family
Courtesy Lyn Hiatt
Kim Hiatt’s mother, Sharon Crum, was a nurse. Her father, Dan Hiatt, was a physician. He moved the family from West Virginia to Seattle for his residency at the University of Washington when Kim was a few months old.
It seemed like a natural choice when Kim decided to pursue a nursing degree at Pacific Lutheran University in Seattle. In 1986, she accepted an entry-level position on Seattle Children’s Hospital’s toddler floor, where she saw young patients with serious medical conditions that ranged from cancer to cystic fibrosis.
Kim fell in love with the profession—and her patients. She specialized in taking care of children who were dying and helping their families with the bereavement process. “She used to write poetry about her patients,” Crum says. “She just got so involved with them. She loved little kids. She was good at her job, and she knew it.”
“You are such a wonderful advocate for your patients and families,” Kim’s supervisor, Cathie Rea, wrote in Kim’s 2009 annual performance review. But in her 2010 review, Rea raised the possibility that Kim might care too much.
“Kim, you do a great job at the bedside with your patients and families,” wrote Rea, who ran Seattle Children’s Hospital’s intensive care units. “You are able to connect with families in a way that makes them feel valued and special. One of your peers commented that they would hate to see you get hurt by giving so much of yourself to families.”
The “second victim” crisis
Albert Wu, MD, began studying medical errors in the late 1980s, as a newly minted medical school graduate. He’d been told to “study what you know.” He knew, from firsthand experience, that his fellow residents made mistakes, sometimes serious ones.
“Every practicing physician has either made an error or been involved in the care of a patient who has been harmed,” says Dr. Wu, who directs the Johns Hopkins Center for Health Services and Outcome Research.
A new line of research that Dr. Wu began found that many health-care providers experience emotional trauma in the wake of a serious medical error. One 2009 study found that two thirds reported “extreme sadness” and “difficulty concentrating.” More than half experienced depression; one third said they avoided caring for similar patients afterward, for fear of making a similar mistake. Some consider suicide—and a smaller fraction, like Kim Hiatt, take their own lives.
In May 1989, Dr. Wu mailed a survey to 254 residents training at major hospitals in the United States about whether they’d made medical errors and, if so, how they coped. A total of 114 residents returned the survey and admitted they had made at least one significant mistake. Some of them said the errors helped them get better at their jobs by, for example, making them more careful about checking data. On the other hand, 13 percent said they became more secretive about their errors.
But the most common thread was that residents just didn’t know what to do. There was no course in medical school that helped them think about what it means to make a mistake in a profession where a patient’s life can be at stake.
“Some of them had caused deaths,” Dr. Wu says. “People were pretty devastated, but they were not talking to anyone about it.”
A fatal error—and two deaths
Around 9:30 a.m. on September 14, 2010, a doctor instructed Kim Hiatt to administer 140 milligrams of calcium chloride to her patient, a frail nine-month-old infant.
Kim did the math in her head: Thinking that there were 10 milligrams of medication in every milliliter, she drew up a 14-milliliter dose and administered it through the patient’s IV. She labeled the patient’s name band and syringe with the time and size of the dosage.
Around lunchtime, another doctor noticed the patient’s heart rate spiking. A nurse drew a blood sample that showed her calcium levels to be elevated. Kim discussed the dosage with another nurse and worked through her math.
The other nurse pointed out the error: There were 100 milligrams of medication for every milliliter, not 10. Kim should have administered only 1.4 milliliters. She had given the patient 14.
Kim was terrified. “I’ve given too much calcium,” the nurse, Michelle Asplin, recalled Kim having said.
Kim entered a note into the patient’s record: “Miscalculated in my head the correct [dosage] according to the mg/ml. First med error in 25 [years] of working here. I am simply sick about it.”
As soon as Cathie Rea, Kim’s supervisor, read the note, she escorted Kim to her car and told her to leave the campus. Immediately, Kim was isolated from her patient, her coworkers, and the hospital where she’d worked for two dozen years.
Kim drove home, panicked about what would happen to her patient. “[Kim] called me on her way home. She said, ‘I gave the wrong dose … and she’s going downhill, and it’s my fault,’” her widow, Lyn Hiatt, said. “She was worried about the parents. She tried to get information from the hospital, but they told her not to call.”
The patient died five days after the error. Seattle Children’s Hospital fired Kim shortly afterward.
Kim struggled with both the death of her patient and the loss of a career she loved. “She wept constantly,” Crum says of her daughter. “She was questioning her self-worth.”
The Washington State Department of Health’s investigation of the incident took about five months. Kim wrote the state investigators a lengthy statement about why she hoped to keep her credentials. “Nursing is my passion and the very core of who I am,” she wrote.
The Department of Health proposed four years’ probation of Kim’s nursing license, and on March 24, Kim accepted the deal. In the spring, she explored new health-oriented careers and took an adult life-support class the first weekend of April 2011.
Lyn remembers when Kim called her on the way home from the second day of class. “She told me she got the highest grade in the class,” Lyn said. “She goes, ‘But no matter how well I do, I’m never going to be able to practice nursing. It’s never going to be enough.’”
That was April 3, 2011. After Kim arrived home, Lyn and their son decided to take a walk to a nearby restaurant. Kim said she would stay home and do laundry. Lyn estimates they were gone for about an hour and a half. During that time, Kim hanged herself in the basement.
Mistakes will happen. How will hospitals react?
Cristina ByvikSue Scott remembers when her first patient died. There was no mistake made—the location of a gunshot wound appeared to guarantee the patient’s death—but she still struggled with the gravity of his death.
“When I had my first experience [of a patient dying],” says Scott, a patient-safety expert at the University of Missouri, “I said something to the nurse I was working with, like, ‘I don’t know if my heart can take this.’ Her response was, ‘Welcome to nursing. You better buck up.’”
Scott decided to try something she thought might help. She launched a hotline that doctors, nurses, and other providers at the University of Missouri could call in the wake of an adverse event. Health-care workers can reach a peer responder at any hour of any day.
The hotline had no relationship with the hospital’s legal department, and it didn’t require callers to provide their names or any other identifying information, in order to make them more comfortable speaking openly. It was the first such hotline in the country, possibly in the world.
This idea, on its own, is controversial. Some safety experts at other hospitals say they’ve faced opposition from patient advocacy groups, which argue that the providers committing harm shouldn’t get these resources.
“There is real resistance in places,” says Dr. Wu. “Some of that comes from patient advocates or injured patients. [They] view themselves as being victimized by the health-care system. So the idea that there should be a service provided to the perpetrator gets met with some pushback.”
In Missouri, preliminary evidence seems to suggest the hotline is working. Scott published a paper that found that providers served by the program were more likely to think the hospital had a “nonpunitive response to errors” and generally perceived their units as offering safer care.
“People here are still afraid to admit their mistakes”
About 500 people attended Kim’s memorial service on April 10, 2011, at the University of Washington’s leafy arboretum. Lyn remembered seeing Kim’s former colleagues and patients in attendance. “One of the moms of a former patient talked about how Kim cared for her daughter when she had a transplant, how she made it a fun time for her,” she said.
Seattle Children’s Hospital says it made policy changes in the wake of Kim’s death. It now more rigorously regulates verbal orders for medication—the type Kim had gotten—an important preventive step that leaves less room for misinterpretation. Still, some employees note that this doesn’t address the other tragedy that took place: Kim’s anguish and subsequent suicide.
“People here are still afraid to admit their mistakes,” says one Seattle Children’s Hospital employee who requested anonymity, “because they are afraid of losing their jobs.”
Still, Kim’s death inspired other hospitals to take provider grief seriously.
Cheryl Connors was working as a patient-safety fellow at Johns Hopkins University in 2011. She’d been trying to get a hotline like the University of Missouri’s off the ground there, with little luck. Nothing about it felt urgent; providers had made do without one for decades. Then, during a meeting, someone mentioned Kim’s story. “That was really our impetus to take action,” Connors said. “Six months later, we implemented our program”—Resilience in Stressful Events, or RISE.
The RISE phone line is staffed with volunteer peer responders who are also health-care providers. When RISE launched in 2011, it averaged one call per month. Now it’s up to five.
RISE takes barely any personal information from callers. This policy helps providers speak honestly and aims to prevent any involvement with the legal system. But it also presents a drawback; it’s hard to study whether the peer support makes any difference when the program can’t identify whom it has supported. That can make getting resources a tough sell to hospital executives who watch the bottom line.
“I’m an outcomes researcher, so it breaks my heart that we don’t have good data,” Dr. Wu says. “It’s hard to justify in your budget. If you haven’t drunk the Kool-Aid, is this something you’re willing to invest money in?”
So far, most hospitals have decided the answer is no. Only a handful have hotlines similar to the one the University of Missouri started in 2007—out of more than 5,000 hospitals in the United States.
The actual work of building one of these hotlines—securing a phone number, finding volunteers, advertising the resource—is not a massive lift. Rather, creating a place where health-care providers are not just allowed but also encouraged to discuss their mistakes is a huge mental leap for a system that routinely demands secrecy. Most American hospitals aren’t there yet.
Medicine ran in Kim’s family, but her daughter Sydney isn’t sure if that tradition will continue. She’s a 21-year-old college student who remembers tagging along with her mom to visit the hospital when she was younger. When I met Sydney in 2015, she told me that seeing her mom’s work—how much she loved it, how she helped people—inspired her to consider a career in health care. At the same time, she approaches the field with some trepidation. Sydney saw the anguish her mother went through when her patient died. “I’m kind of scared to go into health care,” Sydney told me. “I don’t know how I’d handle being the cause of someone’s death.”