Hospital officials said the error was made by one nurse who simply gave an incorrect dose of magnesium sulfate. Like most people who read this story, I have tremendous sympathy for the family of that woman and child. But the person who I can't get off my mind is the nurse who gave the overdose, for whom my overwhelming emotion is also one of sympathy.
Like most doctors and nurses, I have made mistakes during my career. But I cannot recall making such an obvious error that so directly resulted in a patient's death. It is almost mind boggling to think of what must be going through that nurse's mind. How can she live with the knowledge that she caused a woman's death? Is she having suicidal thoughts? What defense mechanism can she employ to let her live with herself? She is apparently an experienced, excellent nurse. Anyone can make mistakes. Could that have been me making such an error? Am I a better health care provider than her, or just luckier?
My hospital has been participating in a perinatal safety project run by the Institute for Healthcare Improvement (IHI). The IHI would blame not so much the nurse here as the system or process. Every process that may result in danger to a patient, such as giving magnesium sulfate, should have some redundancy and safety checks built into it. Maybe more than one nurse needs to check the dose or IV rate; maybe there need to be maximums on how much magnesium sulfate can be put into one IV bag; maybe some other process change is needed. But safeguards are needed for everything in medicine, to prevent the one time in a hundred or a thousand that someone makes a potentially deadly mistake - not only for the health of patients, but also for the emotional health of medical workers.
P.S. Pediatric Grand Rounds is up at Unintelligent Design.