Fatal mistakes

Kim Hiatt had worked as a nurse for 24 years when she made her first medical error: She gave a frail infant 10 times the recommended dosage of a medication. The baby died five days later.

Hiatt's mistake was an unnecessary tragedy. But what happened next was an unnecessary tragedy, too: Seven months after the error, Hiatt killed herself.

"She fell apart," her mother, Sharon Crum, says. "I suppose it would be the same thing you felt, if you felt at fault for a child's death."

This is a story about Hiatt, the mistake she made, how she struggled with that tragedy, and how the institutions that had previously supported her ultimately shut her out.

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 often goes unnoticed: Every day, our healers quietly live with those they have wounded or even killed. Their ghosts creep into exam rooms, their cries haunt dreams, and seeing new patients can reopen old wounds.

"Every practicing physician has either made an error that harmed a patient or certainly been involved in the care of a patient who has been harmed," says Albert Wu, who directs the Johns Hopkins Center for Health Services and Outcome Research.

A new line of research that Wu began in the 1990s has found that many health care providers experience anguish, turmoil, and emotional trauma in the wake of a serious medical error. The providers are, in Wu's view, "second victims" of the mistake.

Just like their patients, these providers struggle to make sense of how an effort to heal turned into serious harm. One 2009 study found that two-thirds of providers reported "extreme sadness" and "difficulty concentrating" in the wake of harming a patient. 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 Hiatt, take their own lives.

Nurses and doctors rarely discuss mistakes with their colleagues. Bringing attention to a mistake feels like highlighting one's own incompetence. Clinicians know that their peers have somehow managed to survive these events and turn up to work each day. So they try to do the same.

"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 to my wife what had happened. What do you say when you almost killed a patient? I was a horror show."

It's easy to write off these providers' anguish as insignificant next to that of the patients and families they've harmed. They made a horrible, harmful mistake. 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.

And as any clinician will tell you, even the best doctors make mistakes — if we are going to have a medical system, then we are going to have medical errors. So it's important not only to learn how to prevent all the errors we can, but also to support clinicians when they inevitably do make mistakes.

About a dozen hospitals nationwide — out of 4,000 total — have begun to set up anonymous hotlines where clinicians can call and talk to a peer about their emotional traumas. The idea is to give them a safe space, isolated from the malpractice system or even their own name, to talk openly about their grief. It's a small step toward a shift in medicine, away from a culture that sees mistakes as unspeakable and toward one that recognizes that America's health care providers —people like Hiatt — have suffered tremendously.

I. "She was good at her job, and she knew it"

Medicine ran in the Hiatt family. Kim's mother, Sharon Crum, was a nurse. Her father, Dan Hiatt, was a physician. He moved the family from West Virginia to Seattle when Kim was a few months old for his residency at the University of Washington.

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 nursing position on Seattle Children's toddler floor, where she saw young patients with serious medical conditions that ranged from cancer to cystic fibrosis.

Hiatt immediately fell in love with the profession — and her patients. "She used to write poetry about her patients," Sharon says. "She just got so involved with them; she loved them, she loved little kids. She was good at her job, and she knew it."

Hiatt was particularly involved with her patients' families, her former co-workers and family recall. She was an avid photographer who liked to help the families make scrapbooks in the hospital.

"You are such a wonderful advocate for your patients and families," Hiatt's supervisor, Cathie Rea, wrote in Hiatt's 2009 annual performance review.

In her 2010 review, Rea raised the possibility that Hiatt might care too much and throw herself too deeply into patients' lives.

"Kim, you do a great job at the bedside with your patients and families," Rea, who ran Seattle Children's Hospital's intensive care units, wrote. "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."

In that same review document, Hiatt was asked to describe what she liked about working at Seattle Children's. She wrote, "I love to teach parents and I love to get the parents handling their child as soon [and] as safely as possible and within the parent's comfort zone."

Hiatt's life was closely intertwined with the hospital. She met her spouse, Lyn, working there — and liked to bring her kids to work to show them what she did all day.

"She was really interested in taking care of kids in their last days of lives, and helping with the bereavement process," Lyn Hiatt says.

If Hiatt worked easily with patients, she did struggle with her co-workers at times. Her friends and family are the first to admit that Hiatt had a brash sense of humor, which could offend people.

"She had no filter," says Julie Stenger, a former Seattle Children's nurse who worked with Hiatt. "It was more to get a laugh from people."

There was a time when a co-worker felt she went too far. In the spring of 2008, a colleague filed a sexual harassment complaint against Hiatt. The documentation of the incident available to the public is incomplete; emails reference but don't fully describe it. The hospital disciplined Hiatt, requiring her to adhere to a "performance improvement plan."

Still, Hiatt's subsequent evaluations suggest the complaint was not considered a big problem. Instead, her supervisor at Seattle Children's describes it as something to work on. "I know this has been a difficult year for you and I am proud that you have rallied to a place where you seem more settled," Rea, the ICU director, wrote in her 2008 review. "Please be sure to continue to maintain your best professional behaviors and role model them for others."

Hiatt had her last performance review in August 2010, 20 days before the error. She had recently begun specializing her nursing skills, focusing on operating a life-support machine that helps especially sick children circulate blood. Her review that year described her as a "leading performer," giving her a 4 on Seattle Children's 5-point ranking scale.

Stenger, her former colleague, recalls it as a moment when Hiatt's children were starting to grow up — and Hiatt reacted by digging into her career even more.

"She was excited because her oldest kid was about to go to college and the youngest was kind of doing the pushing-away thing you do in middle school, so she was trying to find her niche professionally," says Stenger. "She really set her sights on that."

II. The "second victim" crisis

Albert Wu 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 — and didn't really know what to do in the aftermath. New doctors didn't want to tarnish their reputations by making a big deal out of a mistake, but they also found that the errors could haunt them.

In May 1989, 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.

114 residents returned the survey and admitted they had made a significant mistake. Some of them responded positively to their mistakes. They said the errors helped them get better, for example, at checking data. Others responded negatively, like the 13 percent who 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 or death can be at stake.

"Some of them had caused deaths," Wu says. "People were pretty devastated, but they were not talking to anyone about it."

Others began to build on Wu's findings, and they've consistently found three basic facts about the relationship between health care providers and their mistakes.

First, errors in medicine are common. One study found that 14.7 percent of medical residents said they had made a medical error in the past three months. A separate paper estimated about half of all clinicians are involved in a "serious adverse event" each year.

Second, in the wake of an error, many health care providers experience significant emotional and sometimes physical duress. One 2000 survey of more than 3,000 doctors in the United States and Canada found that 81 percent reported experiencing some degree of emotional distress in the wake of an error.

A small, qualitative study conducted in 2007 included 10 in-depth interviews with nurses who made mistakes giving medications. It found that two became depressed and considered killing themselves.

"I felt ashamed, making such a mistake, and that I abandoned others' trust in me," one nurse told researchers. "I felt I gambled with others' trust and love."

Much of the distress focuses, unsurprisingly, on the patient. Rick Boyte, a pediatrician in Mississippi, told me about the moments after a fatal error he had made when his needle accidentally punctured the lung of an already frail infant. The child died within an hour.

"I went and sat in my office for a while, and I just cried," he says. "It was a horrible disaster. I was wondering about the impact of the family, but nobody really knew what to say to me. I remember there were people who just wouldn't engage. They wouldn't look at me. I felt so amazingly terrible."

Third: Most health care providers think their co-workers don't experience emotional duress. This amplifies a sense of isolation, as, for example, a nurse assumes that other nurses navigate their mistakes just fine — that she is the only one who has trouble focusing on patients in the aftermath.

Carol-Anne Moulton is a practicing surgeon at the University of Toronto who struggled when complications happened during operations. If something unexpected happened, her heart raced and her stomach dropped.

But she couldn't tell if her co-workers felt the same way. They never really talked about things like that.

"Around me, it didn't seem like people were experiencing what I was experiencing," Moulton says. "I wondered whether I was unusual or whether this was a common phenomenon."

Moulton decided to answer her own question by talking to her co-workers and publishing the results in an academic journal.

As she interviewed colleagues, she learned about all sorts of emotional harms. One relatively senior surgeon retired early in the wake of an error. Another switched fields. About one-third of surgeons, she found, experienced traumatic stress in the wake of a major medical complication.

"It validated what I was feeling," Moulton says. "Some people who I thought were fairly stoic and resilient expressed way more emotion than I expected."

But here's the most interesting part of her study: All those surgeons who suffered quietly and alone thought that their co-workers were just fine. They assumed they were the only ones reacting emotionally to their errors. As one surgeon told Moulton, "I'm a little more sensitive than they are, and certainly a couple of them are absolute rocks."

Except they aren't: Moulton's paper — and the body of research it fits into — consistently finds that most providers aren't rocks at all.

"The way we've been trained, it's very much not a thing you talk about," Moulton says. "Personally, doing this study helped me with my own reaction. Once you realize you're not alone, you start understanding why you feel this way."

III. A fatal error — and two deaths

Around 9:30 am on September 14, 2010, a doctor instructed Kim Hiatt to administer 140 milligrams of calcium chloride to her patient, a frail 9-month-old infant.

The story of what happened that day is captured in more than 1,000 pages of hospital documents, employee testimony, and personal statements submitted to an ensuing state investigation into the error. These records were accessed through a public records request with the Washington State Department of Health. Vox has made the documents available at the bottom of this story.

Hiatt 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 that through the patient's IV. She labeled the patient's name band and syringe with the time and size of the dosage.

Things in the children's intensive care unit began to get busy. Hiatt recalled the infant's nutritionist arriving with questions, and then her parents came for a visit.

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. Hiatt described 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. Hiatt should have only administered 1.4 milliliters — not 14.

Hiatt was terrified. "Oh, God, I've given too much calcium," the nurse, Michelle Asplin, recalled Hiatt having said.

Hiatt entered a note into the patient's record: "Miscalculated in my head the correct according to the mg/ml. First med error in 25 of working here. I am simply sick about it."

Cathie Rea, Hiatt's supervisor, was elsewhere in the hospital, but she read the note through a computer system. She quickly came down to the patient's room, escorted Hiatt to her car, and told her to leave campus. Immediately, Hiatt was isolated from her patient, her co-workers, and the hospital where she'd worked for two dozen years.

Alyse Bernal, a Seattle Children's spokesperson, declined to comment on whether this was the hospital's protocol for responding to serious medical errors.

"Seattle Children's is committed to providing the safest, most effective care possible," she said in a statement. "We were deeply saddened by the situation that occurred, and it spurred us to closely examine and improve our systems and processes."

Hiatt 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 and I don't know what to do," her widow, Lyn Hiatt, said. "She was worried about the parents and were the parents okay. She was trying to get information from the hospital, but they told her not to call."

Hiatt called the hospital daily to get an update from the patient's bedside nurse. "As a nurse, her wellbeing was foremost on my mind," Kim said in a statement after the error.

The patient died four days after the error. Seattle Children's Hospital fired Hiatt shortly afterward.

It's impossible to untangle how each of those events affected Hiatt's life, because they happened in such quick succession. Hiatt struggled with both the death of her patient and the loss of a career she loved. Friends and family say that after September, she was a different person.

"I saw a person who was totally demoralized," Crum says of her daughter. "She wept constantly; she was questioning her self-worth."

"She was in such a state of despair," says Stenger, who worked with Hiatt at Seattle Children's. "My observation was she was already punishing herself plenty for what happened before they fired her. It was really heart-wrenching to see."

Seattle Children's policy requires the reporting of fatal drug overdoses to the Washington State Department of Health. The hospital reported the incident on September 28, the day after a local television station reported on it.

The investigation took about five months, and in the interim Hiatt looked unsuccessfully for a new job. She ended up doing some work for a friend's landscaping company and rewiring the electricity in her own house. She spent a month in Costa Rica, trying to figure out a plan for what would come next.

She 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. "I want to finish my career doing what I do best, and I truly believe that I could make a difference in the lives of my patients."

On February 3, the Washington Department of Health sent Hiatt a proposed punishment: four years' probation of her nursing license. She would not have to admit any wrongdoing but, during that time, she couldn't have any managerial responsibilities and would need to get the state to sign off on any nursing employment she pursued.

Hiatt accepted the deal. In the spring, she had some moments of determination. She tried to explore new health-oriented careers and took an adult life-support class the first weekend of April 2010.

Lyn remembers when Hiatt called her on the way home from the second day of class.

"I asked her how it went, and she told me she got the highest grade in the class," Lyn said. "She goes, ‘Yeah, but no matter what I do, no matter how well I do, I'm never going to be able to practice nursing.' I was telling her, ‘You've got time; you don't know that. And she was saying, ‘No, it's never going to be enough.'"

That was April 3, 2010. Hiatt finished her drive and arrived home. Lyn and their son decided to take a walk to a nearby restaurant to get milkshakes and fries. Hiatt said she would stay home and do some laundry.

Lyn estimates they were gone for about an hour and a half. During that time, Kim hanged herself in the basement.

IV. Mistakes will happen. How will hospitals react?

Hospital leaders and state regulators must make decisions about how to respond to providers' errors. Experts say there is often a tendency to respond with harsh punishment, to reprimand nurses and doctors for how they harmed a patient.

"No one has much tolerance for mistakes in this medical system," says Hopkins's Wu. "Not only do we judge ourselves harshly, our colleagues tend to not be so charitable. They'll say things that are at best gossipy and at worst sound like bullying. There is discipline; people are certainly chastised, scolded, and fired."

But knowing that our health care system depends on human beings who are fallible — and knowing that most providers will berate themselves internally, sometimes experiencing depression or suicidal urges — some hospitals have begun to think about a different approach.

Sue Scott is a patient safety expert at the University of Missouri, where she runs a 24/7 peer support service for health providers who've experienced traumatic events. She remembers when her first patient died. There was no mistake — the location of a gunshot wound appeared to guarantee the patient's death — but she still struggled with the gravity of his death.

"There can be a mindset among some clinicians like, 'Welcome to health care, this is what you signed up for,'" Scott says. "When I had my first experience [where a patient died] like this, 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 runs all patient safety efforts in her hospital system, and about a decade ago she gathered staff to talk about how they handled similar traumatic incidents — and whether they felt they needed help.

The answer was a resounding yes. The 2007 survey found that 175 providers there had experienced a patient safety event within the past year that caused personal problems like anxiety or depression.

More than two-thirds of those respondents — 68 percent — reported receiving no institutional support.

Later that year, 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 providers 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 pushback from patient advocacy groups, which argue that the doctors committing harm shouldn't get these resources.

"There is real resistance in places," says Hopkins's Wu. "Some of that comes from patient advocates or injured patients. Those are cases, which I totally understand, where they view themselves as having being victimized by the health care system. So the idea that there should be service provided to the perpetrator gets met with some pushback."

Hospital legal departments can also raise an eyebrow at these programs, which they worry could increase providers' liability in malpractice suits.

"Naively, we thought there wouldn't be any problem setting something up to support providers," says Rick van Pelt, the Brigham and Women's anesthesiologist, who helped create a program similar to Missouri's in Boston. "But there was immediate pushback. We had to be really careful making sure this was about well-being, and not about getting information that could ultimately be subpoenaed."

In Missouri, preliminary evidence seems to suggest the hotline is working. Scott published a paper this past fall in the Patient Safety and Health Quality Journal that looked at how those who experienced traumatic events fared before and after the hotline launched.

She found that providers served by the new program were more likely to think the hospital had a "nonpunitive response to errors" and generally perceived their units to offer safer care.

V. "People here are still afraid to admit their mistakes"

About 500 people attended Hiatt's memorial service, held on April 10, 2011, at University of Washington's leafy arboretum. Lyn Hiatt remembered seeing former colleagues and patients in attendance.

"There was an open mic, and 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 and a good time for her daughter, not the horrific time everyone said it would be," she said.

Seattle Children's Hospital says it made policy changes in the wake of Hiatt's death. It now more rigorously regulates verbal orders for medication — the type Hiatt got — which leaves less room for misinterpretation and confusion.

This change had to do with error prevention — trying to make it less likely that another mistaken overdose will happen at that hospital. These preventive steps are important, as hospitals continually attempt to improve best practices for patient safety. Still, some employees note that this doesn't address the other tragedy that took place: Hiatt's anguish and subsequent suicide.

"I think people here are still afraid to admit their mistakes, based on what happened in that scenario," says one Seattle Children's Hospital employee, who requested anonymity to speak openly about their employer. "I don't think people admit mistakes, because they are afraid of losing their jobs."

Still, Hiatt'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 Missouri's off the ground there, with little luck.

It was one of those projects where there would be meetings and talk but no action. Nothing about the hotline felt especially urgent; providers had made do without one for decades.

"It was the type of thing where there was a lot of discussion and planning, but we didn't take action until 2011," Connors says. "As we were sitting at a table talking about what we were going to do, somebody mentioned the story of Kim Hiatt's suicide. That was really our impetus to take action. Six months later we implemented our program."

Connors had never met Hiatt; she had only read about what happened. But she saw how nurses at her hospital could be equally vulnerable. In November 2011, she worked with Albert Wu to found Resilience in Stressful Events, or RISE.

RISE, much like the Missouri program, offers round-the-clock hotline support to providers dealing with traumatic events. The phone line is staffed with 30 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.

"A lot of people call when there is death and it doesn't have to be related to an error," Connors says. "When patients die, staff are traumatized, especially if it's the first time it ever happened."

The logistics of running the hotline can be tricky. RISE offers in-person assistance, but most callers don't want co-workers to know they use the service. They try to schedule meetings in "neutral locations" where others won't overhear them using the program.

RISE barely takes any personal information from callers, like full names or phone numbers. This helps providers speak honestly and aims to prevent any involvement with the legal system.

"In the unlikely situation we were to be subpoenaed and asked, ‘Did you talk to so and so?' we would say, ‘I think so, but I actually didn't catch their last name,'" Wu says.

The anonymous nature of the program also presents a setback; it's hard to study whether the peer support makes any difference when the program can't identify whom it's supported in the first place. That can make getting resources a tough sell for hospital executives who watch the bottom line.

"I'm an outcomes researcher, so it breaks my heart that we don't have good data," 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?"

Most hospitals have, so far, decided the answer is no. Only about a dozen have hotlines similar to the one Missouri started in 2007 — and there are more than 4,000 hospitals in the United States. Hopkins, Missouri, and the handful of other hospitals with hotlines represent a small sliver of the health care system. Seattle Children's looks more like the majority.

"Seattle Children's is not unique," Judith Huntington, executive director of the Washington State Nurses Association, said. "This tragedy could have happened at any hospital. ... Some things have changed in some places [after Hiatt's death], but they haven't changed nearly enough."

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 providers are not just allowed but encouraged to discuss their mistakes is a huge mental leap for a system that routinely demands secrecy. Most American hospitals aren't there yet.

What gets them there might not be stories like Hiatt's. Steve Pratt helped set up the provider support program at Massachusetts General Hospital in Boston. He argues that the pressure will have to come from patients — who don't want to receive care from a traumatized nurse or doctor — in order for the health system to work differently.

"I see it as a moral imperative that clinicians get care," he says. "They're suffering physical and emotional injury. But none of that will drive this forward. The idea that another patient could be harmed — that the error would hurt someone else receiving care — ultimately will."

Medicine ran in the Hiatt family, but Kim's daughter, Sydney, isn't sure if that's true anymore. 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 last fall, she told me that her seeing her mom's work — how much she loved it, how she helped people — inspired her to consider a career in health care. She recently took a summer EMT training course, and sees that as a possible career.

At the same time, she approaches the field with some trepidation. Sydney saw the anguish her mother went through when her patient died, and that was terrible. "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."

This article is the third in Vox's series on fatal medical harm. Reporting for this series is sponsored by the Association of Health Care Journalists' Reporting Fellowship on Health Care Performance and supported by the Commonwealth Fund.

If you are considering suicide, please seek help through the national suicide prevention lifeline at 1-800-273-8255.