When the parents of 8-month old Kaia Zautner brought her to Seattle Children’s Hospital to treat a heart condition, they believed they were leaving her in safe hands. Kimberly Hiatt, 50, was a veteran nurse with 24 years of unblemished service and a friend of the mother, Alana Zautner. The couple had every reason to think that Hiatt, who was already familiar with little Kaia, was the right person to take care of their baby.

But on September 14, Hiatt made a critical error when she administered calcium chloride. Instead of dispensing 140 milligrams as needed, Hiatt dispensed 1.4 grams. Immediately realizing her mistake, she quickly got help from other nurses. They did what they could, but the damage had been done.

Hiatt submitted a report on the hospital’s electronic feedback system that day, stating, “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 yrs. of working here. I am simply sick about it. Will be more careful in the future.”

The mistake proved to be very serious, as it “exacerbated cardiac dysfunction” in Kaia, sending her health into a steep decline. Doctors and nurses did everything they could to restore her health. Kaia’s parents requested that Hiatt not care directly for their child anymore, but they did not set out to punish Hiatt for her mistake.

According to an investigation by the hospital’s director of the ICU, Cathie Rea, the couple were “very calm and reasonable people – understandably upset, but continued to say they ‘didn’t want us to cut off anyone’s head over this.” Five days after the overdose, Kaia passed away.

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In the immediate aftermath, the hospital put Hiatt on administrative leave, firing her shortly after. “She was a wreck,” said Julie Stenger, 39, a critical care nurse who worked alongside Hiatt. “No one needed to punish Kim. She was doing a good job of that herself.”

State investigators determined that it would be difficult to legally prove that the overdose contributed to Kaia’s death. Her state of health was such that any myriad of troubles could have led to her death. No doubt the overdose made it worse, but it’s unclear as to whether or not there was a direct correlation. Instead, Hiatt was fined $3,000, 80 hours of new coursework on medication administration, and probation in which she would be supervised while administering drugs.

Hiatt believed that her future as a nurse was coming to an end. “She said, ‘Who’s going to touch me? I’ve made a mistake,’” shared Hiatt’s mother, Sharon Crum. “When she lost this job, it wasn’t just the job she lost, it was her future.”

“She was devastated, just devastated,” said Hiatt’s partner, Lyn. “Kim’s nursing practice was incredible. She was smart, she was quick.”

Seven months after the incident, on April 3rd, Kimberly Hiatt hanged herself in her family’s home. Her memorial ceremony a week later was attended by nearly 500 people.

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The aftermath of her death resulted in a myriad of reactions from medical professionals. Many nurses developed an elevated anxiety regarding any mistake they make. According to Sally Watkins, assistant executive director of nursing practice, education and research for the Washington State Nurses Association, “Punitive actions are actually counterproductive. Everything in the literature points to that not being the right step to take. Nurses in that unit or hospital will not report things. There’s this heightened awareness: It could be me.”

To err is human. Kimberly Hiatt made a tragic mistake, but a mistake nonetheless.