Kimberley Hiatt was 50, a nurse for 24 years, she worked in the Cardiac Intensive Care Unit at Seattle Children’s Hospital. In September 2010 she accidentally overdosed an 8-month-old infant with calcium chloride as a result of a mathematical error. Ms Hiatt, immediately reported the event to colleagues. Unfortunately, the child didn’t survive the error. The hospital put Hiatt on administrative leave and soon dismissed her. It broke her heart when she was dismissed, not just because she lost her job but also because she lost a child. In the following months, she battled to keep her nursing license in the hope of continuing the work she loved. Six months after the event, Ms Hiatt died by suicide.
The suffering of caregivers in the face of a serious medical error has been termed the ‘second victim’ phenomenon. These individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, seriously doubting their clinical skills and knowledge base. They may suffer from extreme fatigue, sleep disturbances, increased Blood Pressure, muscle tension, frustration, decreased job satisfaction, difficulty concentrating, flashbacks, loss of confidence and grief or remorse.
The risk factors for suicide among health professionals, including doctors, are similar to those found in the general population. However, there are some additional risks among doctors such as their unwillingness to seek timely help, access to potent drugs and the skills to self-medicate. Other risk factors include exclusion from work, poor support networks, ongoing investigations, complaints, court cases, inquests and multiple jeopardy from having a complaint considered by a range of bodies including employers and the GMC.
Scott’s 3-tiered interventional model of support for Second Victims is well recognised (Ref: https://www.muhealth.org/app/files/public/1405/Scotts_Three_Tier_Support.pdf)
It’s too late for Kimberly, but her story can serve as a catalyst for a much needed change in healthcare – support for second victims of errors.
“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”
- Don Norman Author, the Design of Everyday Things
Dedicated training for all medical students and GPs in suicide prevention must be made mandatory in the NHS and all over the world as prevention of harm means prevention of first and second victims. However, as long as humans are a part of any system, errors will occur. To err is human.
This post is so helpful because it is a reminder to me that system failure needs to be the focus of our son’s forthcoming inquest. Thank you!
Thank you for your comment. I wish you strength for the upcoming inquest. Please make sure you have enough support on the day. Sending you lots of love, S. xxx