Remembering Kim Hiatt: Casualty of Second Victim Syndrome

Kimberly Sue Hiatt was a critical care nurse at Seattle Children's Hospital. In April 2011 she took her own life, and her death forced a hard question into the open: was the punishment that followed her single medication error ever proportionate to what happened?

In September 2010, Hiatt gave 1.4 grams of calcium chloride instead of the calculated 140 mg dose, 10 times the intended amount, to a critically ill 8-month-old infant. She had worked at the hospital for more than two decades with an excellent record, and investigators found this was her first medication error. It devastated her.

The infant died five days later. Within weeks Hiatt was suspended and then fired. The state nursing commission placed her on a four-year probation that required supervision whenever she administered medication, a condition that made finding another nursing job nearly impossible. She died by suicide seven months after the error.

She had not hidden anything. She logged the error in the hospital's electronic reporting system the same day: "I messed up. I've been giving CaCl (Calcium Chloride) for years. I was talking to someone while drawing it up. Miscalculated in my head the correct mls according to the mg/ml. First med error in 25 years of working here. I am simply sick about it. Will be more careful in the future."

The infant was already gravely ill with a severe cardiac condition from birth, and it was never proven that the error caused her death. State investigators acknowledged the child's fragile condition and poor prognosis would have made causation hard to establish legally. Still, the cardiologist who treated her, Dr. Harris P. Baden, said the mistake "exacerbated cardiac dysfunction" and contributed to her decline.

Hiatt's case is a stark example of "second victim syndrome," the term Dr. Albert Wu of the Johns Hopkins Bloomberg School of Public Health coined for the clinician wounded by a serious medical error. The infant died, and so, in a different way, did her nurse.

The second victim

Her death exposed something most people never think about: nurses and doctors are profoundly affected when these incidents happen, and the impact can be fatal. It is a cruel paradox. A nurse who never intended harm still carries the guilt, blame, and anger, often turned inward. On top of that comes isolation and rejection from the profession itself, the kind of emotional trauma that can break a person.

There are moments when any clinician makes a grave error, and the resulting sense of inadequacy tends to fester in private. Working with blood, death, and near-misses is never comfortable. That weight likely haunted Hiatt, who could not bear the thought that she had contributed to the death of a baby she had set out to save.

The deepest cut is realizing your training did not make you immune. Hiatt was a top performer with glowing reviews, and it still happened. Clinicians are expected to anticipate mistakes, yet no one teaches anyone how to forgive them for it. Her error was unintentional and not a pattern of safety violations. She was not a difficult employee. She was fired anyway.

"To eliminate them is futile, you will make errors," said Mary Z. Taylor, a director of patient safety at the Washington University School of Medicine in St. Louis. "You may think things are safer if you've gotten rid of that person, but that's not necessarily so."

Expectations are hurting nurses

Nurses are expected to absorb emotional pain and commit zero errors, as if they have thicker skin than everyone else. Hiatt's case put the administration under scrutiny for upholding such rigid expectations. When mistakes are inevitable, why should nurses face inflexible standards that leave no room to be human? For a nurse who loved her job, losing it ended the dream, and the support that might have helped her through the aftermath was not there.

Nurses take an oath to "abstain from whatever is deleterious and mischievous." One error, an overdose, a missed medication, a fall, and a nurse meets accusatory eyes. No one in their right mind wants to harm anyone, yet a career of upholding nonmaleficence can be erased by a single mistake. Telling a struggling nurse that they should leave the profession if they cannot handle it is just insensitive. Some nurses are far harder on themselves than anyone else, and that self-punishment can turn dangerous. It did for Hiatt.

"More often than not, the more idealistic the healer is, the more intense he or she would feel in terms of depression and trauma and inadequacy," one California nurse said.

Hiatt's honesty became a liability. She could have stayed quiet and did not. That is moral fiber, and it went unrecognized. A Washington State Nurses Association survey in the months after her death found that half of respondents believed a mistake would be held against them, and nearly a third hesitated to report an error or safety concern for fear of retribution. Punitive cultures buy silence at the cost of honesty.

Suicide is preventable

Depression and anxiety are quiet killers, and the regret after a suicide is sharpest when it might have been prevented if anyone had seen what was happening. A January survey of more than 8,000 participants in the Archives of Surgery found that surgeons who believed they had made a serious error were more likely to have considered suicide. The survey did not include nurses, but there is little reason to think nurses are any different.

The reality is that mistakes are universal. What matters is whether a clinician can use them as lessons rather than a verdict. When a healer asks for help and no one comes, the result is the burnout that drives nurses out of the profession, and sometimes worse. Hiatt's story is one of missed chances. Had she been given a path back, she might be teaching today about how even the best nurses are prone to terrible mistakes. Her death became a message the profession could not ignore, one that went unheard while she was alive.