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Question
In 2010, a nurse at Seattle Children's Hospital's Cardiac Intensive Care Unit (CICU) was working her regular shift when she made a serious medication error. Kimberly Hiatt, a dedicated nurse with over 20 years of experience at the hospital, mistakenly administered 1.4 grams of calcium chloride instead of the prescribed 140 milligrams to a patient. After realizing her mistake, Kimberly immediately disclosed the error to her colleagues. Tragically, the 8-month-old patient, Kaia Zautner, passed away following the medication error. While it is uncertain whether Kimberly's error directly caused the child's death, it did worsen the baby's cardiac condition and contribute to her decline. Despite the tragic outcome, legal difficulties in proving causation between the overdose and the patient's death made the situation complex. Subsequently, Kimberly was placed on administrative leave and ultimately terminated from her position. Sadly, a few months later, on April 3rd, Kimberly took her own life. What is one strategy you can suggest to your peer so that they can avoid the error/sentinel event they described?
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